Near Misses in Neuroanesthesia [Mīkstie vāki]

Contributing Authors xi Preface xv Acknowledgments xvii Part I: Airway Events Alterations in Airway Pressures High-Peak Inspiratory Pressure during a Craniotomy in a Prone Position 3(4) Kim L. Walker Wade Weigel Pneumothorax after a Central Venous Catheterization 7(4) Terry T. Durbin Biting a Reinforced Endotracheal Tube 11(2) Terry T. Durbin Hazards of Surgery in a Prone Position 13(4) Donald E. Martin Alterations in Carbon Dioxide Tension Inability to Eliminate Carbon Dioxide during Placement of a Ventriculoperitoneal Shunt 17(2) Kathleen S. Donahue Loss of CO2 Trace 19(4) Janice Omlor Loss of CO2 Trace during a Pediatric Craniotomy 23(4) Lester T. Proctor III Air Embolism 27(4) W. Andrew Kofke Inability to Isolate Lungs with a Double-Lumen Endotracheal Tube 31(2) Nicholas A. DeAngelo Awake Intubation Apnea during an Awake Intubation 33(4) J. Clark Venable Patient Uncooperative with an Awake Intubation 37(4) J. Clark Venable Retching during an Awake Intubation-Failed Nerve Blocks 41(4) Jay C. Johnson Postoperative Airway Events Stridor in the Postanesthesia Care Unit in a Patient Status Postanterior Cervical Discectomy 45(4) Stephen J. Kimatian Stridor after Embolization of Vascular Lesions of the Oral Pharynx 49(6) John W. Jamieson Part II: Cardiac Events Alterations in Blood Pressure Increase in Arterial Blood Pressure during Microvascular Decompression for Trigeminal Neuralgia 55(4) Daniel P. Williams Hypertensive Response to Patient Positioning for Lumbar Spine Surgery 59(4) Garfield B. Russell Increased Blood Pressure and Bradycardia during Acetabular Repair Two Days after an Emergency Evacuation 63(2) Maria T. Roth Hypertension during Interventional Neuroradiology Emoblization Procedure 65(4) Thomas Long No Arterial Blood Pressure Trace after Placement in a Lateral Decubitus Position 69(2) Afreen Siddiqui Gradual Loss of Pulse Oximetry Trace in Down Extremity in the Lateral Decubitus Position 71(4) Stephen J. Kimatian Excessive Hypotension before Surgical Incision (Inadvertent Rapid Infusion of Vancomycin) 75(4) Leon O. Wright Iliac Vein Injury during L5-S1 Discectomy 79(4) Michael A. Weaver Sudden Decrease in Arterial Blood Pressure during an Anterior Lumbar Disc Fusion 83(4) Joseph Gabriel Hypertension during an Interventional Neuroradiology Embolization Procedure (Full Bladder) 87(4) Thomas J. Long Inability to Float a Flow-Directed Catheter in an Interventional Neuroradiologic Procedure 91(4) Terri W. Blackburn Hemodynamic Instability during the Resection of a Cerebellopontine Angle Tumor (Undiagnosed Glomus Tumor) 95(4) Alan A. Artru Severe Hypotension during a Ventriculoperitoneal Shunt Revision 99(4) Kim L. Walker Wade Weigel Electrocardiogram Changes Widened QRS Complex with Rapid Sequence Induction (Hyperkalemia with Motor Neuron Lesion) 103(4) Uriel A. Yodfat Electrocardiogram Changes during Hyperventilation for a Craniotomy (Hypokalemia from Acid/Base Shifts) 107(4) Stephen Longo Bradycardia during a Posterior Fossa Craniotomy 111(4) Fernando A. Gutierrez Kathleen S. Donahue Electrocardiogram Changes Noted during the Preoperative Evaluation for Clipping a Cerebral Aneurysm 115(2) Charles P. Kingsley Asystole during Induction of a Two-Month-Old Child for a Ventriculoperitoneal Shunt (Inadvertent Carotid Massage with Cricoid Pressure) 117(2) Lester T. Proctor III Arrhythmia in the Surgical Intensive Care Unit after Excision of an Acoustic Neuroma 119(4) Patricia Schupfer Electrocardiogram Changes during Selective Arterial Infusion of Papaverine for the Treatment of Cerebral Vasospasm (Papaverine Causing a Decrease in Coronary Artery Perfusion Pressure) 123(6) Francis G. King Part III: Miscellaneous Perioperative Events Preoperative Severe Pain Preoperative for Lumbar Disc Surgery 129(2) Atulkumar Kshatri Respiratory Depression in a Cervical Spine-Injured Patient on the Night of Surgery 131(4) Francis G. King Seizure on Induction for Clipping a Cerebral Aneurysm 135(4) John W. Jamieson Disseminated Intravascular Coagulation Following Head Trauma 139(4) Paul J. Teiken Excessive Patient Movement during an Awake Craniotomy 143(2) Terri W. Blackburn Failure of Uncooperative Trauma Patient to Arouse after General Anesthesia for Repair of Femur Fracture 145(2) Kane M. High Postoperative Failure to Breathe after a Posterior Fossa Craniotomy 147(4) John E. Reynolds Acute Postcraniotomy Agitation 151(4) Arthur J. Cronin Diabetes Insipidus after Pituitary Surgery 155(6) Paul J. Teiken Part IV: Neurophysiological Events Changes in Brain Stem Auditory Evoked Responses Ipsilateral Loss of the Auditory Evoked Potential during an Acoustic Neuroma Resection 161(4) Arthur J. Cronin Changes in Somatosensory Evoked Potentials Loss of Somatosensory Evoked Potentials in a Patient in a Sitting Position 165(4) Arthur J. Cronin Loss of Amplitude of the Left Ulnar Somatosensory Evoked Potential during a Scoliosis Repair 169(2) Arthur J. Cronin Loss of All Evoked Potentials during Posterior Spinal Instrumentation 171(4) Arthur J. Cronin Changes in Motor Evoked Potentials Sudden Loss of Motor Evoked Potentials during a Posterior Cervical Spine Fusion 175(4) Arthur J. Cronin Decrease in the Amplitude of Motor Evoked Potentials Bilaterally 179(4) Maria T. Roth Forane Bolus for Elevated Blood Pressure 183(4) Joseph Gabriel Index 187