WebM&M: Case Studies

A seven-year-old girl with esophageal stenosis underwent upper endoscopy with esophageal dilation under general anesthesia. During the procedure, she was fully monitored with a continuous arterial oxygen saturation probe, heart rate monitors, two-lead electrocardiography, continuous capnography, and non-invasive arterial blood pressure measurements. The attending gastroenterologist and endoscopist were serially dilating the esophagus with larger and larger rigid dilators when the patient suddenly developed hypotension. She was immediately given a fluid bolus, phenylephrine, and 100% oxygen but still developed cardiac arrest. Cardiopulmonary resuscitation was initiated with cardiac massage, but she could not be resuscitated and died. This commentary highlights the role of communication between providers, necessary technical steps to mitigate the risks of upper endoscopy in children, and the importance of education and training for care team members.

First admitted to the hospital at 25 weeks of pregnancy for vaginal bleeding, a woman (G5 P2 A2) received 4 units of packed red blood cells and 2 doses of iron injections. She was discharged after 3 days with an improved hemoglobin level. At 35 weeks, she was admitted for an elective cesarean delivery. Intraoperatively, an upper uterine segment incision was made and the newborn was delivered in good condition. Immediately after, a subtotal hysterectomy was performed. The anesthesiologist noted that the patient was hypotensive; blood was transfused. A rash developed surrounding the transfusion site and widespread ecchymosis appeared as she became more unstable. Although physicians attempted to stabilize her with fluids and medications and cardiopulmonary resuscitation was performed for 60 minutes, the patient died.

Following surgery under general anesthesia, a boy was extubated and brought to postanesthesia care unit (PACU). Due to the patient's age and length of the surgery, the PACU anesthesiologist ordered continuous pulse-oximetry monitoring for 24 hours. Deemed stable to leave the PACU, the boy was transported to the regular floor. When the nurse went to place the patient on pulse oximetry, she realized he was markedly hypoxic. She administered oxygen by face mask, but he became bradycardic and hypotensive and a code blue was called.

Admitted to gynecology due to excess bleeding and low hemoglobin after elective surgery, an older woman developed severe pain, nausea, and new-onset atrial fibrillation. She was moved to the telemetry unit where cardiologists treated her, and she had episodes of bloody vomit. Intensivists consulted, but the patient arrested while being transferred to the ICU and died despite maximal efforts.