231J.G. Brock-Utne, Case Studies of Near Misses in Clinical Anesthesia, DOI 10.1007/978-1-4419-1179-7, © Springer Science+Business Media, LLC 2011

AAbnormal EKG

general anesthesia, 215left bundle branch block, 217

Acinetobacter baumannii, 19Aidinis, S.J., 5, 6Air embolus, 165Airway hemorrhage, 130Airway leak, 141Airway obstruction. See also Pharyngeal mass

nasopharyngeal airway, 68oral surgery, bleeding, 201

Airway protection, 5Airway difficulty, 225Alcohol consumption, 193, 194Aliason, I., 165Allen’s test

Brodsky’s test, 90Doppler plethysmography, 90oximeter, 90spasm/thrombosis, 89

Amar, D., 8Amyotrophic lateral sclerosis (ALS)

diaphragmatic pacer (DPS), 51, 53ETT, 51general anesthesia, 53sudden cardiac arrest (SCA), 53

Anesthesia machineairway leak, 141apneic oxygenation, 93esophageal stethoscope, 141ETT, 141

Anesthesiologist. See Exhausted anesthesiologist

Antiphospholipid antibody syndromeautoimmune dry eyes, 64

corneal abrasion, 64general anesthesia, 63ocular injuries, 64

Aortic valve replacement, 145

Apneic oxygenation, 94Apollo anesthesia machine. See Anesthesia

machineArmored endotracheal tube. See Reinforced

endotracheal tubeAsai, H., 53Atlanto-axial dislocation, 21Atrial fibrillation (AF)

EKG, 173treatment, 175

Autoimmune dry eyes, 64Awake nasal intubation, 226

BBai-Han, L., 120Bariatric surgery

aspiration, 86cricoids pressure, 86

Barrett’s esophagitis, 55Beattie, C., 68Beta-receptor antagonist eye drops,

120BH filter, 20Bispectral index scale (BIS)

awareness, anesthesia, 161electromyographic (EMG), 161ETT, 159hypoglycemia, 161midazolam, 161

Bladder rupture, 50

Index

232 Index

Blood glucose levelsginseng, 207noninsulin-dependent diabetes, 209

Body mass index (BMI). See ObesityBody temperature

electrocautery, 178laparoscopy, 178

Botox injections, 228Bradshaw, P., 120Bridenbaugh, L.D., 74Brodsky, J.B., 206Brodsky’s test, 90. See also Allen’s testBronchopleural fistula, 82Bronchoscope, 190Bronchoscopy, 130Bronchospasm

endotracheal tube insertion, 83intravenous lidocaine, 83, 84

Bunionectomyplaster cast burn, 224postoperative analgesia, 223skin graft, 224

CCalcium chloride administration, 16Capnograph, 37–40, 50, 94, 144, 212Cardiac arrest

CPR, 195, 196neurosurgery, 196prone patient, 195–196pulseless electrical activity (PEA), 196

Cardiac arrest, ICUcardiopulmonary resuscitation, 219propofol infusion, 219resuscitation drugs, 219

Cardiac compass histogram, 88. See also Pacemaker implantation

Cardiac cripple, 97, 98Cardiac rhythm, 88Cardiopulmonary resuscitation (CPR)

cardiac arrest, 195, 196epinephrine, 108, 165neonatal laparoscopic surgery, 163–165

Carina obstruction, 2Cervical collar, 77Cheng, M.A., 152Chilaiditi’s sign, 25Chronic pain. See also Spinal reconstruction

and fusionpatient, physical examination, 230

Chung, F., 46Code Blue, 107–108Coffee ground emesis, 11, 13

Cohen, S., 8Communication, 11Compartment syndrome, 13Convulsion

alcohol consumption, 193hypoglycemia, 194regional anesthesia, 193–194

Cordis catheterinferior vena cava (IVC), 210internal jugular vein (IJV), 209, 210triple lumen, 209, 210

Corneal abrasion, 64Coronary artery bypass graft, 15–16CPR. See Cardiopulmonary resuscitation

(CPR)Cricoids pressure, 30, 52Cuff-leak volume test, 17Cyanosis, 59Cyst, fourth ventricle

neurocysticercosis, 191removal of, 191transsphenoidal approach, 191valsalva’s maneuver (VM), 192

Cystoscopy, epinephrine, 123

DDefibrillator pad, 106Denture fixation. See Fixed denturesDiaphragmatic pacer (DPS), 51, 53DiFrancesco,V., 86Doppler plethysmography, 90Double lumen endotracheal tube

lung transplant, 205size, 205, 206thoracic incisional injury, 81tracheal diameter, 205, 206

Dromedary sign, 39

EEKG/ECG. See Abnormal EKG;

Atrial fibrillation (AF); Cardiac cripple

Electrocautery, 178Electromyography (EMG), 161Embolization, 130Endobronchial foreign body

bronchoscope, 1902.0 Fogarty catheter, 190

Endotracheal intubationETT, 139pilot balloon, 139, 140vaginal pack, 139

233Index

Endotracheal tube (ETT)airway hemorrhage, 129amyotrophic lateral sclerosis (ALS), 51anesthesia machine, 141bispectral index scale (BIS), 159bleeding source, 129blood, 125bronchoscopy, 129capnograph tracing, 37cuff-leak test, 17denture fixation, 35embolization, 130endotracheal intubation, 139fiberoptic intubation, 21insertion, 5neonatal laparoscopic surgery, 163pharyngeal mass, 101preeclampsia, 117pulmonary hemorrhage, 129removal, 3respiratory arrest, 155thoracic anesthesia, 129total IV anesthesia (TIVA), 167transesophageal echocardiography (TEE),

109trendelenburg position, 199

Epidural analgesia, 27Epidural blood patch, 7Epinephrine, 108, 123Epsilon-aminocaproic acid (Amicar),

15, 16Esophageal stethoscope, 141, 142Esophagectomy, 29Exhausted anesthesiologist, 115

FFiberoptic intubation, 21Fixed dentures, 35Fogarty catheter, 190Fujiki, M., 188Fujimura, N., 25

GGastroesophageal reflux disease (GERD), 76General anesthesia

abnormal EKG, 215amyotrophic lateral sclerosis (ALS), 51antiphospholipid antibody syndrome, 63bariatric surgery, 85esophagectomy, 29fixed dentures, 36mediastinal mass, 1

nasogastric tube insertion, 61perioperative stroke (POS), 181pharyngeal mass, 101retained surgical sponges, 105shoulder reconstruction, 43spinal reconstruction and fusion, 147

Ginseng action, 208GlideScope, 62Grant, G.P., 152

HHalanski, M.A., 224Hematoma, 203Hemicolectomy, 61Heparin, 146Herbal medication. See Ginseng actionHiccups

cochlear implant, 183contractions and movement, head, 184facial nerve dissection, 184muscular paralysis, 184orogastric tube, 183in pediatrics, 185

Hicks, S.D., 74Hyperkalemia, 15Hypoglycemia, 161Hypotension, 144

IICU patient

coagulation status, 171erythema, 16918-G IV, 169multisystem dysfunction, 171supraclavicular nerve catheter, 171ventilator, 170

Infection risk, 19, 20Inferior vena cava jugular filter, 210Internal jugular cannulation

PEEP application, 188positive end expired pressure, 187

Interscalene block, 23Intraocular pressure (IOP). See Postoperative

visual loss (POVL)Intravenous lidocaine, 83, 84Ischemic optic neuropathy. See Postoperative

visual loss (POVL)

JJaffe, R.A., 38, 39Jean, J., 86

234 Index

KKrane, E., 64

LLabor pain, 27Lalwani, K., 165Lanca, J., 208Laparoscopic Nissen fundoplication, 178Laparoscopy complication

bladder rupture, 50capnograph, 50pneumoperitoneum, 49

Laryngeal mask airway (LMA)APL valve, 111aspiration pneumonia, 113regurgitation, 113succinylcholine, 113

Left bundle branch block (LBBB), 217Lighthall, G.K., 94Lipid infusion, 74LMA Supreme, 42LMWH. See HeparinLocal anesthetic toxicity

elbow surgery, 73endotracheal tube, 75lipid infusion, 74severe systemic reactions, 74

Lung function test, 33Lung transplant. See Double lumen

endotracheal tube

MMAC. See Monitored anesthesia care (MAC)Magnesium sulfate, 117, 118Mahajan, R., 68Mazer, S.P., 196McConnell attachment, 43, 44McCulloch, T.J., 161Mediastinal mass, 1Messina, M., 25Metabolic acidosis

acetazolamide, 222extracranial–intracranial revascularization,

221single-photon emission CT scan (SPECT

scan), 221Metastatic melanomas, 1Missing laps. See Retained surgical spongesMobbs, P.A., 68Monitored anesthesia care (MAC)

bleeding disaster, 138

endotracheal tube, 137epistaxis, 137nasal trumpet, 138turbinate cancer, 137

Moore, D.C., 74Motorcycle accident injury.

See Neck injuryMyasthenia gravis (MG),

33, 34

NNasogastric (NG) tube

GlideScope, 62hemicolectomy, 61insertion of, 62

Nasopharyngeal airway, 68Neck injury

airway examination, 79cervical collar, 77CT scan, 77

Negron, M., 8Neonatal laparoscopic surgery

air embolus, 165duodenal atresia, 163ETT, 163trendelenburg position, 165

Neosynephrine drip, 125Neurocysticercosis cyst, fourth ventricle, 191Neuromuscular blockers. See HiccupsNeuromuscular function, 5

OObesity

BMI, 199trendelenburg position, 199

Ocular injuries, 64Oral surgery, bleeding

airway obstruction, 201coagulation study, 202hematoma, 203sertraline (SSRI), 201

Orringer, M.B., 56Orthopedic trauma

arterial line, 127blood pressure level, 126epinephrine, 127intraosseous infusion, 127neosynephrine drip, 125

Outpatient anesthesia, 45Oxygen supply

anesthesia machine, 93

235Index

apneic oxygenation, 94oxygen source, 94respiratory acidosis, 94

PPacemaker implantation

asynchronous mode, 88cardiac histogram, 88

Paradoxical vocal cord motion disorder (PVCM), 70

Patient discharge criteria, 46, 47Perioperative stroke (POS)

arm weakness, 179brain MRI, 181general anesthesia, 179risk factor, 181

Permanent teeth, 36Persistent intraoperative hiccups.

See HiccupsPharyngeal mass

airway obstruction, 103chest X-ray, 101ETT, 103general anesthesia, 101pharyngoscopy, 101respiratory disaster, 103sevoflurane, 103tracheostomy, 101

Pharyngoscopy. See Pharyngeal massPilot tube repair kit, 140Pituitary tumor. See Transsphenoidal

resectionPlaster cast burn, 224Plastic surgery. See Botox injectionsPneumoperitoneum, 49POS. See Perioperative stroke (POS)Positive end expired pressure, 187Postdural puncture headache, 7Postoperative visual loss (POVL)

betaxolol eyedrops, 152intraocular pressure (IOP), 152ischemic optic neuropathy, 151lumbosacral laminectomy, 151

PreeclampsiaETT, 140Lactate Ringer, 117magnesium sulfate, 117, 118muscle relaxant, 118respiratory arrest, 117, 118

Pulmonary artery catheter (PAC), 109, 130

Pulmonary function, 25

Pulmonary hemorrhage, 130Pupil abnormalities, 148, 149PVCM. See Paradoxical vocal cord motion

disorder (PVCM); Respiratory distress

Pyridostigmine, 33

RRegional anesthesia. See BunionectomyRegional block, 97Reinforced endotracheal tube

cyanosis, 59occlusion, 60tracheostomy, 59

Respiratory arrestepidural blood patch, 7ETT, 157IV, 155, 157recovery room, 155vecuronium, 155

Respiratory distress. See also Pharyngeal mass

epidural, labor pain, 27fiberoptic laryngoscopy, 70gastroesophageal reflux disease (GERD),

70incidence of, PVCM, 70peribronchial thickening, 69PVCM, 70salpingo-oophorectomy, 69

Respiratory distress syndrome, 13Retained surgical sponges

defibrillator pad, 106orthotopic liver transplant, 105

Rocuronium, 227, 228Rosenblatt, M.A., 74

SSertraline (SSRI), 201Shoulder reconstruction, 43Sniffing technique, 18Spinal anesthetics, 121Spinal reconstruction and fusion

chronic pain, 147, 148general anesthesia, 148pupil abnormalities, 148, 149

Strain gauge plethysmography, 90Stroke. See Perioperative stroke (POS)Sudden cardiac arrest (SCA), 53Superficial temporal artery, 144Supraclavicular nerve catheter, 171

236 Index

TTest dose

beta blockers, 120ECG/EKG, 119epidural catheter, 119, 120IV epinephrine, 120

Thoracic duct repairaspiration, 55Barrett’s esophagitis, 55cricoids pressure, 56transhiatal esophagectomy, 56

Thoracic incisional injurybronchopleural fistula, 82double-lumen tube, 81, 82

Total IV anesthesia (TIVA)awareness, 168ETT, 167IV fluid, 168posttraumatic stress disorder (PTSD), 168

Tracheal diameter. See Double lumen endotracheal tube

Tracheostomy. See also Airway difficultyairway pressures, 133reinforced endotracheal tube, 59respiratory distress, 135

Transesophageal echocardiography (TEE)endoscopic evaluation, 110esophageal stethoscope, 110ETT, 109midazolam, 109pulmonary artery catheter (PAC), 109temperature probe, esophageal, 110

Transsphenoidal resectionaortic valve replacement, 145bleeding/clotting, 146heparin, 146pituitary tumor, 145warfarin, 146

Trendelenburg positioncuff-leak test, 17ETT, 200obesity, 199shoulder reconstruction, 43

Turbinate cancer, 137

UUrmey, W.F., 25

VValsalva’s maneuver (VM), 192Vancomycin, 108Vaporizer

anesthesia machine, 212intraoperative awareness, 212mydriasis, 213sevoflurane, 211

VP shunt, 41

WWarner, M.A., 152Weinberg, G., 74