Crisis Management in Anesthesiology. Edition No. 2

Table of Contents

1. Fundamentals of Dynamic Decision Making in Anesthesia

2. Specific Principles of Anesthesia Crisis Resource Management

3. Teaching Anesthesia Crisis Resource Management

4. Debriefing

5. Generic Events

Acute Hemorrhage

Cardiac Arrest

Difficult Tracheal Intubation

Emergent (Crash) Induction of Anesthesia

Esophageal Intubation

High Inspired CO2

High Peak Inspiratory Pressure

Hypertension

Hypotension

Hypoxemia

Operating Room Fire

ST Segment Change

The Septic Patient

The Trauma Patient

6. Cardiovascular Events

Acute Coronary Syndrome

Anaphylactic and Anaphylactoid Reactions

Autonomic Dysreflexia

Cardiac Tamponade

Nonlethal Ventricular Arrhythmias

Pulmonary Edema

Pulmonary Embolism

Sinus Bradycardia

Supraventricular Arrhythmias

Venous Gas Embolism

7. Pulmonary Events

Airway Burn

Airway Rupture

Anterior Mediastinal Mass

Aspiration of Gastric Contents

Bronchospasm

Endobronchial Intubation

Epiglottitis (Supraglottitis)

Hypercarbia

Hypoxemia During One-Lung Ventilation

Massive Hemoptysis

Pneumothorax

Postoperative Stridor

Unplanned Extubation

8. Metabolic Events

Addisonian Crisis (Acute Adrenal Insufficiency)

Diabetic Ketoacidosis

Hyperkalemia

Hypoglycemia

Hypokalemia

Hyponatremia and Hypo-osmolality

Hypothermia

Malignant Hyperthermia

Metabolic Acidosis

Methemoglobinemia

Oliguria

Thyroid Storm

Transfusion Reaction

9. Neurologic Events

Central Nervous System Injury

Local Anesthetic Systemic Toxicity

Perioperative Visual Loss

Peripheral Nerve Injury

Postoperative Alteration in Mental Status

Postoperative Failure to Breathe

Seizures

10. Equipment Events

Carbon Monoxide in the Anesthesia Circuit

Circle System Expiratory Valve Stuck Closed

Circle System Inspiratory Valve Stuck Closed

Circle System Valve Stuck Open

Common Gas Outlet Failure

Drug Administration Error

Electrical Power Failure

Faulty Oxygen Supply

Gas Flow Control Malfunction

Intravenous Line Failure

Loss of Pipeline Oxygen

Major Leak in the Anesthesia Breathing Circuit

Pop-Off Valve Failure

Ventilator Failure

Volatile Anesthetic Overdose

Waste Anesthesia Gas Disposal System Malfunction

11. Cardiac Anesthesia Events

Cardiac Laceration

Coagulopathy Following Cardiopulmonary Bypass

Emergent "Crash" onto Cardiopulmonary Bypass

Hypotension During Cardiopulmonary Bypass

Low Cardiac Output State Post-Cardiopulmonary Bypass

Massive Systemic Air Embolism

Protamine Reaction

12. Obstetric Events

Amniotic Fluid Embolism (also termed Anaphylactoid Syndrome of Pregnancy)

Cardiac Arrest in the Parturient

Difficult Airway in the Parturient

Emergency Cesarean Section

Hypotension Following Neuraxial Anesthesia

Magnesium Toxicity

Obstetric Hemorrhage

Pre-eclampsia and Eclampsia

Total Spinal Anesthesia

13. Pediatric Events

Acute Hemorrhage in the Pediatric Patient

Anaphylaxis in the Pediatric Patient

Aspiration of a Foreign Body

Bradycardia in the Pediatric Patient

Cardiac Arrest in the Pediatric Patient

Difficult Airway Management in the Pediatric Patient

Hypotension in the Pediatric Patient

Laryngospasm

Masseter Muscle Rigidity

Sinus Tachycardia in the Pediatric Patient

Authors

David M. Gaba Associate Dean for Immersive & Simulation-based Learning and Professor of Anesthesia, Stanford University; Staff Anesthesiologist and Director, Patient Simulation Center of Innovation, VA Palo Alto Health Care System, Palo Alto, California. David Gaba is a Professor, Anesthesiology, Perioperative and Pain Medicine and Associate Dean for Immersive and Simulation-based Learning in Stanford University School of Medicine. Kevin J. Fish Professor Emeritus, Anesthesiology, Pain and Perioperative Medicine, Stanford University, Stanford, CA; Per diem Staff Anesthesiologist, Anesthesiology and Perioperative Care Service, Veterans Affairs Palo Alto Health Care System, Palo Alto, CA. Steven K. Howard Associate Professor of Anesthesia, Stanford University School of Medicine; Staff Anesthesiologist Anesthesiology and Perioperative Care Service, VA Palo Alto HCS, Palo Alto, California. Steven Howard is a Professor, Med Center Line, Anesthesiology, Perioperative and Pain Medicine and Chair, Clinical Competence Committee, Department of Anesthesia. Amanda Burden Associate Professor of Anesthesiology, Director Simulation Program, Cooper Medical School of Rowan University, Cooper University Hospital, Camden, New Jersey. Amanda Burden is a Professor of Anesthesiology, Cooper Medical School of Rowan University and Director, Simulation Program, Cooper University Health Care.