A 78-year-old woman with macular degeneration presented for a pars plana vitrectomy (PPV) under monitored anesthesia care (MAC) with an eye block. At this particular hospital, eye cases under MAC are typically performed with an eye block by the surgeon after the anesthesiologist has administered some short-acting sedation, commonly with remifentanil. On this day, there was a shortage of premixed remifentanil and the resident – who was unfamiliar with the process of drug dilution – incorrectly diluted the remifentanil solution.
A 34-year-old morbidly obese man was placed under general anesthesia to treat a pilonidal abscess. Upon initial evaluation by an anesthesiologist, he was found to have a short thick neck, suggesting that endotracheal intubation might be difficult. A fellow anesthetist suggested use of video-laryngoscopy equipment, but the attending anesthesiologist rejected the suggestion. A first-year resident attempted to intubate the patient but failed.
Silver Springs, MD: US Food and Drug Administration: June 25, 2021.
Ruskin KJ, ed. Curr Opin Anaesthesiol. 2020;33(6):774-822.
A 56-year-old female received a digital tourniquet around the base of her left big toe during an ablation and excision of a deformed in-grown toenail.
MedWatch Safety Alert. Silver Spring, MD: US Food and Drug Administration. June 2, 2020.