Case Archive
Pediatric Anesthesiology
Ref. # 84328

A three week old Missouri infant underwent surgery for cataract removal. During induction of anesthesia, the infant sustained cardiac arrest due to Halothane overdose. After extensive CPR, the infant was resuscitated. She was left with mental and physical deficits including cerebral palsy. A medQuest pediatric anesthesiologist opined that, in light of the child's congestion, the surgery could have been postponed. The subsequent complications were avoidable.

Pediatric Anesthesiology
Ref. # 15328

A Nebraska newborn underwent surgical repair of Type II truncus arteriosus and Type B interrupted aortic arch. Surgery for pyloric stenosis was performed that month, as well. Eight months later the baby underwent elective revision of the heart structures, reconstruction of the right ventricular outflow tract with bifurcated homograft, and elongation of ascending aorta with interposition ascending aortic graft. Pre-op bloodwork showed hematocrit of 37.4 and hemoglobin of 2.9. Prior to the second surgery, hematocrit was 24. Apparently cardiac tamponade was suspected. Exploration of the mediastinum controlled the bleeding. Post-op the baby developed severe cerebral atrophy, with evidence of a significant, diffuse neurological event. A medQuest pediatric anesthesiologist reported there was an inappropriate pump run for the bypass surgery, especially in light of the irregular lab values. The baby's neurological event was avoidable.

Pediatric Anesthesiology, Pediatric Nephrology
Ref. # 17108

A Michigan boy was born with Prune Belly Syndrome and suffered multiple complications during the first two years of his life, including bilateral congenital hip dysplasia. He was admitted to the hospital for an elective surgery to remove a left acetabular pin. During induction of general anesthetic the patient arrested, resulting in hypoxic/anoxic encephalopathy. A medQuest pediatric anesthesiologist reported the cardiac arrest was probably secondary to hyperkalemia, according to the records. The patient's pre-op work-up was inadequate. A medQuest pediatric nephrologist reported the patient had a history of kidney and electrolyte problems that were not sufficiently considered before the surgery. The patient's arrest was avoidable.

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