Near Misses in Pediatric Anesthesia

1. Case 1: Upper Gastrointestinal Endoscopy Under General Anesthesia
John G. Brock-Utne

2. Case 2: Sudden Anesthesia System Failure
John G. Brock-Utne

3. Case 3: Broviac Catheter Placement in a Neonatal Intensive Care Unit
John G. Brock-Utne

4. Case 4: Occluded Reinforced (Armored) Endotracheal Tube
John G. Brock-Utne

5. Case 5: The Too-Small Rigid Bronchoscope
John G. Brock-Utne

6. Case 6: Anaphylaxis, Anaphylactoid Reaction, or What Was It?
John G. Brock-Utne

7. Case 7: Generalized Convulsions After Regional Anesthesia
John G. Brock-Utne

8. Case 8: Hypotension During Microdiscectomy
John G. Brock-Utne

9. Case 9: Intraoperative Hypotension in a Patient Receiving Chronic Steroids
John G. Brock-Utne

10. Case 10: Changing a Nasotracheal Tube for an Oral Tube in the Intensive Care Unit
John G. Brock-Utne

11. Case 11: Blocked Intravenous Line During Rapid-Sequence Induction
John G. Brock-Utne

12. Case 12: Postinduction Difficult Intubation
John G. Brock-Utne

13. Case 13: Blunt Upper Airway Trauma in a Patient with Recent Polysubstance Abuse
John G. Brock-Utne

14. Case 14: The Stuck Elevator
John G. Brock-Utne

15. Case 15: Postoperative Upper Airway Obstruction
John G. Brock-Utne

16. Case 16: Postoperative Respiratory Complications in a Neonate
John G. Brock-Utne

17. Case 17: Pregnant Teenager with a Bad Outcome
John G. Brock-Utne

18. Case 18: Tension Pneumoperitoneum
John G. Brock-Utne

19. Case 19: A Patient with Status Asthmaticus
John G. Brock-Utne

20. Case 20: Intraoperative Decrease in Electrocardiogram Amplitude: Cause for Concern?
John G. Brock-Utne

21. Case 21: Potential Disaster: An Intravenous Line That Stops Working in the Perioperative Phase
John G. Brock-Utne

22. Case 22: Ventilatory Management in Major Thoracic Incisional Injury
John G. Brock-Utne

23. Case 23: Airway Leak in a Prone Patient
John G. Brock-Utne

24. Case 24: Difficulty in Extubation
John G. Brock-Utne

25. Case 25: Tonsillectomy
John G. Brock-Utne

26. Case 26: An Unusual Cause of a Serious Cardiac Arrhythmia
John G. Brock-Utne

27. Case 27: A Patient with Supraglottic Mass
John G. Brock-Utne

28. Case 28: Pressurized Intravenous Hetastarch
John G. Brock-Utne

29. Case 29: Intraoperative Hypotension
John G. Brock-Utne

30. Case 30: Hematuria
John G. Brock-Utne

31. Case 31: Congenital Complete Heart Block
John G. Brock-Utne

32. Case 32: Neonatal Respiratory Distress
John G. Brock-Utne

33. Case 33: Respiratory Distress in the Intensive Care Unit
John G. Brock-Utne

34. Case 34: The Butterfly Needle (Abbott)
John G. Brock-Utne

35. Case 35: Hypotension on Induction of Anesthesia in a Trauma Patient
John G. Brock-Utne

36. Case 36: Delayed Postoperative Respiratory Obstruction
John G. Brock-Utne

37. Case 37: An Abnormal Capnogram
John G. Brock-Utne

38. Case 38: Retropharyngeal Abscess
John G. Brock-Utne

39. Case 39: Rising End-Tidal Carbon Dioxide
John G. Brock-Utne

40. Case 40: Acute Abdomen
John G. Brock-Utne

41. Case 41: Difficulty in Ventilation in the Postinduction Period
John G. Brock-Utne

42. Case 42: Unexplained Low Oxygen Saturation
John G. Brock-Utne

43. Case 43: Occlusion of an Endotracheal Tube in a Neonate
John G. Brock-Utne

44. Case 44: Surgical Emphysema After a Motor Vehicle Accident
John G. Brock-Utne

45. Case 45: Postoperative Respiratory Arrest
John G. Brock-Utne

46. Case 46: Rapid Increase in Body Temperature After Induction of General Anesthesia
John G. Brock-Utne

47. Case 47: Intraoperative “Oozing”
John G. Brock-Utne

48. Case 48: A Tip for Nasotracheal Intubation
John G. Brock-Utne

49. Case 49: A Case of Anisocoria Following General Anesthesia
John G. Brock-Utne

50. Case 50: A Routine Tonsillectomy and Adenoidectomy
John G. Brock-Utne

51. Case 51: Drug Overdose
John G. Brock-Utne

52. Case 52: Cardiac Arrest in a Neonate
John G. Brock-Utne

53. Case 53: Bilateral Tourniquets. Beware
John G. Brock-Utne

54. Case 54: Neurofibromatosis. A Warning
John G. Brock-Utne

55. Case 55: A Machine Failure
John G. Brock-Utne

56. Case 56: A Severe Case of Bronchospasm
John G. Brock-Utne

57. Case 57: A Peanut in the Airway
John G. Brock-Utne

58. Case 58: A Sprinkler Spike Lodged in a Patient’s Head
John G. Brock-Utne

59. Case 59: Infusion of Cold Blood. Should We Worry?
John G. Brock-Utne

60. Case 60: Respiratory Arrest After Extubation
John G. Brock-Utne

61. Case 61: Sudden Increase in End-Tidal CO2

John G. Brock-Utne

62. Case 62: A Case of Acute Lymphoblastic Leukemia (ALL)
John G. Brock-Utne

63. Case 63: Intraoperative Airway Obstruction
John G. Brock-Utne

64. Case 64: An Anterior Mediastinal Mass. What Will You Do?
John G. Brock-Utne

65. Case 65: A “Routine” MRI Case
John G. Brock-Utne

66. Case 66: A Serious Problem During Neurosurgery
John G. Brock-Utne

67. Case 67: A Case of Severe Intra-abdominal Pressure
John G. Brock-Utne

68. Case 68: A Case of Severe Laryngospasm
John G. Brock-Utne

69. Case 69: An ETT Suction Problem
John G. Brock-Utne

70. Case 70: A Child Refusing an Operation
John G. Brock-Utne

71. Case 71: Why So Sleepy?
John G. Brock-Utne

72. Case 72: Check Your Facts
John G. Brock-Utne

73. Case 73: A Strange Capnogram
John G. Brock-Utne

74. Case 74: Relying on Others
John G. Brock-Utne

75. Case 75: Monitored Anesthesia Care. Watch Out
John G. Brock-Utne

76. Case 76: An Intermittently Worrisome Capnography Trace
John G. Brock-Utne

77. Case 77: Cardiac Arrest at the Conclusion of Neurosurgery
John G. Brock-Utne

78. Case 78: Watch Out
John G. Brock-Utne

79. Case 79: A Complication of Central Venous Cannulation?
John G. Brock-Utne

80. Case 80: An Example of Murphy’s Law
John G. Brock-Utne

81. Case 81: A Tragic Case
John G. Brock-Utne

82. Case 82: Hemoptysis from a 2-Month Tracheostomy
John G. Brock-Utne

83. Case 83: A Potentially Serious Incident
John G. Brock-Utne

84. Case 84: Rusty Material in an Oxygen Flowmeter
John G. Brock-Utne

85. Case 85: A Surprising Solution to an Airway Emergency
John G. Brock-Utne

86. Case 86: An Airway Leak in the ICU
John G. Brock-Utne

87. Case 87: Pediatric Dental Anesthesia
John G. Brock-Utne

Keywords: Medicine & Public Health, Anesthesiology