All comers: 1 in 20k
Patient |
· Young adult · Female · Obese · PHx awareness |
Surgery |
· GA LUSCS (1 in 670) · Cardiac (1 in 8600) · Thoracic · Neuro |
Anaesthesia |
Drugs: · Paralysis 16x (1 in 8k with, 1 in 135k without!) · TIVA (2x) · RSI · Thiopentone Induction problems: · Difficult airway · Hypotension · Transfer from anaesthetic room into theatre |
Circumstances |
· No consultant · Emergency · Out of hours · Busy |
Induction |
50% |
· Esp. forget to turn on gas |
Maintenance |
30% |
· Esp. switch to TIVA |
Emergence |
20% |
· Esp. turn off gas too early |
TIVA |
|
· Esp. switch to TIVA · Esp. non-TCI · Esp. failure to deliver drug (disconnection, IV tissuing) · Esp. during transport |
· Paralyse unnecessarily
· Turn the gas on too late
· Turn the as off to early
· Neglect to re-dose propofol if difficult airway
· Be blasé about TIVA (i.e. proper giving set / line of sight / TCI / EEG)
· Trust processed EEG alone
· Leave drugs unlabelled (especially relaxants, also cefazolin vs thiopentone)
Feedback welcome at ketaminenightmares@gmail.com