Case Studies of Near Misses in Clinical Anesthesia

Case 1. A patient with a mediastinal mass.- Case 2. Stick out your tongue.- Case 3. An epidural blood patch. What went wrong?.- Case 4. A lack of communication leads to a bad outcome.- Case 5. Hyperkalemia during Coronary Artery Bypass Graft.- Case 6. A adjuvant to the cuff leak test.- Case 7. Acinetobacter baumannii outbreak in an ICU. Can our equipment be at fault?.- Case 8. A complication with the use of the intubating Fiberscope.- Case 9. Interscalene block in concern in cardiac patients.- Case 10. Epidural analgesia for labor. Watch out.- Case 11. Past history of esophagectomy. Any concern?.- Case 12. A case of Myasthenia Gravis.- Case 13. Where are my teeth?.- Case 14. An unusual Capnograph tracing.- Case 15. A VP shunt.- Case 16. Shoulder surgery. Watch out.- Case 17. An ambulatory surgical patient with no escort.- Case 18. A complication during laprascopy.- Case 19. A patient with Amyotrophic lateral sclerosis.- Case 20. Repair of a thoracic duct.- Case 21. Occuled reinforced (armored) endotracheal tube.- Case 22. A difficult nasogastic tube insertion.- Case 23. Antiphospholipid antibody syndrome. Any concern for general anesthesia?.- Case 24. An airway surprise.- Case 25. Difficulty with breathing in the postoperative period.- Case 26. Severe systemic local anesthetic toxicity.- Case 27. A motorcycle accident with neck injury.- Case 28. Thoracic incisional injury.- Case 29. Bronchospasm. An unusual cause.- Case 30. Post bariatric surgery. Any concerns?.- Case 31. Valuable information from an implanted pacemaker.- Case 32. Allen's test in an anesthetized patient. Is it possible?.- Case 33. A loss of the only oxygen supply you have during an anesthetic.- Case 34. An aggressive surgeon.- Case 35. A pharyngeal mass.- Case 36. Retained laps.- Case 37. A "Code Blue".- Case 38. A complication of Transesophageal echocardiography (TEE).- Case 39. LMA in elective orthopedic surgery.- Case 40. What would you do?.- Case 41. Preeclampsia.- Case 42. A failed "test

John Brock-Utne is an Emeritus Professor of Anesthesia and a previous Associate Director of the Anesthesia Residency Program at Stanford University School of Medicine.  He has written over 200 peer-reviewed articles and about 400 abstracts and letters, and several books, including Near Misses in Pediatric Anesthesia and Clinical Anesthesia: Near Misses and Lessons Learned.

From the reviews:

"Provides a wealth of tips to prevent perioperative disaster and is ideal for problem-based discussions ... . case scenarios that are informative and useful for practitioners in all anesthetic subspecialties and for those practicing in different environments ... . I would highly recommend this book to anyone practicing anesthesiology ... . It is always prudent to heed the advice of those more experienced than ourselves; with this book, Dr. Brock-Utne has solidified some of those lessons on paper to be shared for the future." (Eric S. Fouliard, Anesthesiology, Issue 4, 2013)"This book includes interesting cases from the author's (and his colleagues') 40+ year anesthesia career. ... The purpose is to present near-miss cases and the etiology of the problems. ... This is a great book for anyone interested, even peripherally, in anesthesia and critical care medicine. It would be a great read for medical students or student registered nurse anesthetists as well as residents and practitioners. It is such an easy read that it can be picked up and put down quickly." (Martin Dauber, Doody's Book Reviews, December, 2011)