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Anesthesiology:
doi: 10.1097/ALN.0000000000000238
Reviews of Educational Material

Near Misses in Pediatric Anesthesia, Second Edition

Erpelding, Timothy J. S. M.D.; König, Matthias W. M.D., F.A.A.P.

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The second edition of Near Misses in Pediatric Anesthesia has been significantly expanded to include almost twice as many cases as the first edition. Otherwise, the format remains largely unchanged: 87 cases are presented in no particular order with a brief vignette followed by clinical questions, case solution and discussion, and—for most cases—a short reference list of either case reports or other pertinent suggested reading. The case presentations are short and succinct, averaging between two and four pages in length. This format makes for very easy reading and should be popular with trainees and junior staff who want to supplement their training or experience with a variety of interesting cases described by an accomplished clinician and teacher.
From the perspectives of not only a trainee but also a teacher, this book provides an interesting compilation of pearls in the diagnosis and management of both commonly occurring pediatric cases (foreign bodies, laryngospasm, and difficult intubations) and zebra cases (missed congenital tracheoesophageal fistula in a 7-yr-old with chronic aspiration masking as asthma and complete airway obstruction from uvulitis), and they certainly are testament to the author’s considerable clinical experience.
After reading through this case compilation, however, we found ourselves wondering whether we were truly reading a book intended for trainees and practitioners in 2014: Bain circuits were used for intraoperative ventilation, thiopental was still available as an induction agent, atropine was routinely administered even to a 3-yr-old, halothane was still popular, and elective anesthetics were induced via a butterfly needle. Although certainly interesting and not without educational merit, we fear that such historic cases along with rather dated reference material are of somewhat limited interest to today’s learner and may actually prove distracting due to unfamiliar drugs and techniques. This compilation also contains more than 30 cases of patients aged 14 to 19 yr, who certainly present with anesthetic issues, but they are not uniquely pediatric in their challenges. In addition, a substantial number of cases center on equipment malfunctions, for example, faulty gas analyzer, stuck valves, and crossover of gas supply pipelines, and likewise, does not present pediatric problems per se but rather concerns patients of all ages. In the end, the reader is left with approximately 40 cases of truly pediatric near misses.
Although any anesthesia provider will agree that there are usually several ways to successfully tackle a difficult situation in the operating room, some of the case resolutions and recommendations made us scratch our heads. In the light of the medico-legal realities of 2014, we would have to respectfully disagree with the author on some of his case solutions: Should we really proceed with a semi-elective appendectomy at a—presumably—small hospital in a patient with complete congenital heart block in the absence of a transvenous pacing option, solely relying on isoproterenol and transcutaneous pacing as our back-up? Should a blind nasal intubation be our first choice in airway management for a decompensating asthmatic child in the emergency room? Should we prepare for a patient with suspected airway difficulties for gastrointestinal endoscopy by asking the endoscopist to load an endotracheal tube onto their smallest gastroscope instead of setting up for video-laryngoscopy or fiberoptic intubation back-up? In the absence of extenuating circumstances, we are concerned that these anesthetic management strategies might prove difficult to defend in case of a poor patient outcome. From a teaching perspective, the above-mentioned cases are all excellent starting points for discussions with trainees, but we would want to discourage the described management plans if they were professed by our residents. At the least, these cases would have warranted a somewhat broader discussion of management options to provide the reader with some perspective.
In summary, this book presents an interesting variety of challenging cases and will be of value to any anesthesia trainee and teacher. Any potential reader looking specifically for pediatric anesthesia case vignettes, however, is likely going to be disappointed because too few of the included cases truly present pediatric anesthetic challenges.
Timothy J. S. Erpelding, M.D., Matthias W. König, M.D., F.A.A.P.
University of North Carolina at Chapel Hill, Chapel Hill, North Carolina (M.W.K.). mkonig@aims.unc.edu

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