A 77-year-old man was admitted for coronary artery bypass graft surgery with aortic valve replacement. The operation went smoothly but the patient went into atrial fibrillation with hypotension during removal of the venous cannula. The patient was shocked at 10 Joules but did not convert to sinus rhythm; the surgeon requested 20 Joules synchronized cardioversion, after which the patient went into ventricular fibrillation and was immediately and successfully defibrillated with 20 Joules. While the patient was being transferred to his gurney, the operating room team noticed that the electrocardiogram cable that enables synchronized cardioversion was only connected into the anesthesia monitor and was never connected to the patient’s defibrillator. The commentary discusses the risks of unsynchronized shocks or pacing, the role of standardized processes to ensure that operating room equipment is prepared and set-up correctly, and the importance of operating room team preparation to urgently address life threatening complications

A patient who was 39-weeks pregnant presented to the hospital in active labor, admitted to the Labor and Delivery unit and confirmed to have a full-term singleton fetus in vertex presentation. After several hours on oxytocin, the fetal head was still relatively high and the fetal heart rhythm suggested hypoxemia. The physician attempted delivery using a vacuum, but ultimately performed an emergency cesarean delivery of a healthy newborn. The procedure was complicated by the need to extend the lower uterine segment incision bilaterally for safe extraction of the fetus. The operator’s note described post-delivery repair of the right uterine incision but did not comment on the left side. Following the delivery, the patient was noted to be hypotensive and tachycardic and went into cardiac arrest. Another physician opened the patient’s incision and found nearly three liters of blood had collected in her abdomen, apparently due to complete transection of the left uterine artery. The commentary highlights the risk factors for obstetric hemorrhage, summarizes standardized risk assessments used to alert for potential obstetric hemorrhage and use of obstetric simulation training to improve team communication and performance.

A 47-year-old obese man with hypertension fell and suffered a cervical spine (C5/C6) fracture. He was scheduled for urgent anterior cervical decompression and fusion and was transferred to the operating room (OR) where general anesthesia was induced. During the procedure, his expired tidal volume decreased from 560 ml to about 330 ml. He was manually ventilated through the endotracheal tube, which proved very difficult. An urgent chest X-ray did not reveal any pneumothorax. The Black Belt cervical retractor was released by the surgeon resulting in complete resolution of the airway obstruction. The commentary highlights the importance of vigilant monitoring and good communication to identify and respond to life-threatening events and describes approaches to improve crisis management during anesthesia events.