NEAR MISSES IN PAEDIATRIC

ANAESTHESIA
Dr A. AJIBADE
DR A.I ORIA
OUTLINE

• Introduction
• Definition
• Risk factors
• Types
• Case studies
• management
• Literature review
INTRODUCTION
• Children constitute a significant and interesting part of the workload in
Anaesthesia practice
• Paediatric Anaesthesia embraces patients from the premature neonate to
adolescent.
• Major differences exist between the anatomy, physiology and pharmacological
response of children and adult.
INTRODUCTION
• WHO defines a near miss as an error that has the potential to cause an advert
event but fail to do so because of chance or it is intercepted.

• According to the institute of medicine, a near miss is an act of commission or

omission that could have harmed the patient but did not cause harm as a result of
chance, prevention or mitigation
INTRODUCTION
• A near miss is an event under anaesthesia care which has the potential to lead to
the substantial negative outcome if left to progress

• A critical incident in anaesthesia is defined as any untoward and preventable

mishap associated with the administration of general or regional anaesthesia, and
which leads to, or could have led to an undesirable patient outcome.

• To reduce the frequency of these factors and errors, the circumstances that
encourage them must be identified and reported. Patients' safety can thus be
improved by learning from reported critical incidents.
INTRODUCTION
• Anaesthesia-related mortality has been on the decline in the past three decades
due to several measures that have been adopted to improve patients' safety.

• Among these is the review of critical incidents and near misses occurring during
anaesthesia as well as factors contributing to these incidents. These factors are
attributable to the patient, surgery or anaesthesia
• It can also be referred to as a near hit, close call or dangerous occurrence
CATEGORIZATION OF CRITICAL INCIDENTS
OAUTHC CASE REPORT
• Anaesthetic machine checked was adequate and complete before the start of the
first case
• At the end of the case, patient was transferred to the PACU
• The Bio-medic unit briefly assessed the Anaesthetic machine before the start of
the second case
• The second patient was moved into the theatre suite to undergo a procedure under
general anaesthesia + ETT
• Baseline vital signs were obtained and patient pre-oxygenated
• At induction of anaesthesia, patient was noticed to be desaturating despite on
100% oxygen
• Bag was noticed to be collapsing despite closure the APL valve
OAUTHC CASE REPORT
• Effort to troubleshoot was unsuccessful and the team requested for an AMBU bag
• Patient’s SpO2 appreciated to 99% despite AMBU bagging in room air
• Patient was allowed to recover from the induction agent with continuous AMBU
bagging
• The oxygen sensor was found with one of the Bio-medic team which was
removed during the machine check-up
OAUTHC CASE REPORT
• 6 months old female infant was worked up for bilateral syndactyl repair of the
hands as a day-case surgery.
• A brief history including the last meal was ascertained from the mother.
• ASA 1
• Baseline vital signs check were done and child was pre-oxygenated then induced
with propofol.
• An appropriate sized laryngeal mask airway was used.
• About 15minutes into the surgery, she was noticed to have suddenly desaturated,
with white substances oozing out through the sides of her mouth.
• Immediately, surgery was put on hold, the table was positioned head down, with
the head in left lateral position.
OAUTHC CASE REPORT CONTD
• The LMA was removed, suctioning was done and the airway was secured with an
appropriate sized endotracheal tube, the surgery continued.
• Patient did well.
• Apparently, the mother breastfed while at the waiting room because she claimed
the child was crying excessively.
CAUSES
• These factors are attributable to the patient
• Equipment's factor(Anaesthesia and monitor not properly checked)
• Parents/guardian note adhering to instructions given as the play a major role in
preparation for surgeries
• Drug errors
• Anaesthesia-related critical incidents may be due to human errors, equipment
errors, or pharmacological factors.
• Human factors(wrong patient identification, wrong drug dose calculations, poor
clinical acumen, poor communication and interpersonal skills,fatigue,distration)
TYPE
• Type 1: an incident that does not reach to the patient because of formal and
planned intervention and programs
• Type 2: an incident that does not reach to the patient because of chance or
unplanned interventions
• Type 3: an incident that does reach to the patient but does not cause harm
because of early detection, interventions and treatment
• Type 4: an incident that does reach the patient but does not cause harm because
of chance
CASE REPORT 1: DIFFICULTY IN
EXTUBATION
• A 14 year old Boy (50kg) scheduled for an emergency appendectomy.
• His history was unremarkable.
• ASA1E
• Baseline vital obtained
• General Anaesthesia was induced with a rapid-sequence technique
• The trachea was intubated with cuffed 5mm internal diameter ETT and was
confirmed
• At the end of the surgery the neuromuscular blockade was reversed.
• Spontaneous respiration returns, but the patient was unable to follow commands.
• He was therefore transported to the PACU with ETT still in place
CASE STUDY: DIFFICULTY IN
EXTUBATION
• He became alert and attempted to remove the ETT
• Attempt to rapidly deflate the ETT cuff, the pilot balloon and the valve assembly are
pulled off the pilot tube.
• The pilot tube is stretched, occluding the stump of the tube that is still attached to
the inflated cuff.
• The cuff is therefore still inflated and, despite several attempts, the ETT cannot be
removed.
• What will you do initially? How will you remove the ETT?
• The patient must be verbally reassured. Sedation may be necessary.
• Deflate the cuff and needle inserted past the occlusion in the stump of the pilot tube.

• Puncture the cuff with a needle either during direct observation using a laryngoscope
or indirectly through the cricothyroid membrane.
• Cut the pilot tube proximal to the obstruction, thereby letting the air out.
CASE REPORT CONT’D: DIFFICULTY IN
EXTUBATION
• Other causes of difficult extubation include inadvertently having the
• ETT wired to facial bones
• sutured to the pulmonary artery
• transfixed by a screw
• stuck to the tracheal mucosa because of absence of lubricant
• wrapped up in the nasogastric tube and fixed below the cords by folds in the
deflated cuff
CASE STUDY: DIFFICULTY IN
EXTUBATION
• Recommendation
• The practice of pulling off the pilot balloon and valve assembly to deflate the
tracheal cuff should be strongly discouraged.
• Besides the complication recorded here, there is the situation in which an
emergency re-intubation of a recently extubated patient is needed. If no other
ETT is available, then the ETT, which is just removed from the patient and intact,
can be used again.
 CASE REPORT 2: OCCLUDED REINFORCED
(ARMOURED) ENDOTRACHEAL TUBE

• An 8-year-old boy presented for a major (ENT) procedure.

• History and examination findings were normal
• ASA1
• A reinforced endotracheal tube (ETT) was used to secure the airway after induction
of general anaesthesia.
• In this case, however, due to surgical reasons, a tracheostomy is not done, and the
patient is taken to the intensive care unit (ICU) with the reinforced ETT in place.
• Tube was left in-situ for mechanical ventilation because of marked head and neck
oedema after 10 hours of surgery.
• Awake on the tube the patient bites down vigorously on the reinforced ETT.
• The lumen becomes completely occluded and will not re-expand.
• Compression of the lumen resulted in oxygen desaturation to 80 %. Cyanosis
becomes evident.
 CASE REPORT2: OCCLUDED REINFORCED
(ARMOURED) ENDOTRACHEAL TUBE

• A hemostat can manipulate the reinforced ETT into its original shape by placing the
hemostat at 90° to the occlusion.
• ETT lumen is open.
• ETT can be cut below the obstruction and pass a tube changer or a gum-elastic bougie

• Recommendation
• A hard bit block, not an oral airway, should always be used with an armoured ETT.
This is to prevent the occlusion of the ETT and even biting the ETT in half.
CASE REPORT 3: TONSILLECTOMY
• A 2-year-old boy who presented for tonsillectomy.
• ASA1
• Baseline Vital signs stable with a heart rate of 90bpm, regular sinus rhythm
• A mask induction, with 100 % oxygen in Halothane up to 4 %.
• Mask ventilation with Halothane 2 % commenced and an intravenous line is
inserted.
• Before any drugs were given, there was a sudden loss of oximetry pulseform and
the alarm goes off.
• Adequate chest exertion is seen with manual ventilation. The electrocardiogram
shows a regular sinus heart rate of 76 bpm.
• No peripheral Pulses palpable. The ECG still shows 76 bpm
CASE REPORT 3: TONSILLECTOMY
• Are you concerned? If so, what will you do?
• Turn the Halothane off.
• Commence cardiopulmonary resuscitation with 100 % oxygen via mask airway.

• Call for a defibrillator.

• Perform endotracheal intubation.
• After these measures, the femoral pulse reappeared, and the oxygen saturation
improved to 100 % with rebound hypertension.
• Despite a peripheral pulse of over 120 bpm, the ECG still showed a regular sinus
heart rate of 76 bpm.
• The oximeter also showed a pulse of 126 bpm.
CASE 3: TONSILLECTOMY
• A decision to proceed with the operation was made after a new ECG machine was
attached to the patient.
• This machine now showed the pulse to be also 126bpm.
• No further problems and the patient was awakened with no neurologically deficit.
• The patient was discharged the next day.
• Most likely, an overdose of Halothane (without preoperative atropine) led to a
severe, rapid-onset bradycardia and arrhythmia.
• On inspection of the ECG machine, it was noted to be a demonstration model
when no pulse detected (e.g., sinus rhythm of 76bpm)
• Recommendation
• When in doubt, examine your patient. If you find no pulses, then there are no
pulses despite an ECG that tells you otherwise
DIAGNOSIS NEAR MISSES SOLUTION

Upper Gastrointestinal Distended epigastrium with Undrape the patient and

Endoscopy Under General injected air to dilate the ensure gastric decompress
Anaesthesia oesophagus and stomach

Sudden Anaesthesia System kinked and compressed fresh Adjust tube and straighten
Failure gas flow tube between the for laminar flow of gas
railing of the operating room
table and the bottom of the
inspiratory pipe on the
absorber
The Too-Small Rigid large leak of fresh gas packing the pharynx
Bronchoscope
Anaphylaxis, or ? 2nd dose of vecuronium Supportive care and
Anaphylactoid Reaction ? Air embolism removing the trigger
? hypovolamia
Generalized Convulsions • Toxin reaction Infusion of 50% D/W
After Regional Anaesthesia • Undiagnosed epileptic
• hypoglycemia
DIAGNOSIS NEAR MISSES SOLUTION
Intraoperative Hypotension lack of systemic A repeat dose of steroid
in a Patient Receiving hydrocortisone raised the BP
Chronic Steroids

During Rapid-Sequence Blocked Intravenous Line Precipitate has been known

Induction to cause complete obstruction
of flow from use of IV
thiopentone and Rocuronium

Postoperative Respiratory right middle and lower lobe Continuous Epidural infusion
Complications in a Neonate collapse till 40hours postoperative

Pregnant Teenager with a Oxygen interchanged with High index of suspicion

Bad Outcome nitrous oxide at supplying
room
DIAGNOSIS NEAR MISSES SOLUTION
Perforated viscous Tension Pneumoperitoneum • Rapid-sequence
induction
• Tracheal intubation in
sitting position

Airway Leak in a Prone Gastric insufflation during orogastric tube

Patient mask ventilation
Intraoperative Hypotension latex allergy Remove any latex materials.

Neonatal Respiratory large neuroenteric cyst Rule out conditions

Distress
An Abnormal Capnogram exhausted CO2 absorbent Replace absorbent
Postoperative Respiratory retransfusion of the cell
Arrest saver blood with
vencuronium

Neurofibromatosis unstable dislocation at C4-5 All patient should have a

cervical spine X-ray
DIAGNOSIS NEAR MISSES SOLUTION

Infusion of Cold Blood Raynaud’s phenomenon Warm blood

Sudden Increase in End- HMEs in paediatric removal of the HME

Tidal CO 2 anaesthesia can cause
hypoventilation and
tachycardia
MANAGEMENT OF NEAR MISSES
• PREOPERATIVE
• It is best prevented than managed
• Extensive and adequate history and examination
• Thorough Investigation
• Daily equipment check
• Training and retraining of staff
• Equipment maintenance
• Proper documentation of critical events
• Proper communication of critical events
• Review of critical events
MANAGEMENT OF NEAR MISS
• INTRAOPERATIVE
• High suspicious index
• Knowledge of the pathology
• Close monitoring of patient
• Keep up with procedure
• Understanding the alarm system
• Daily and intermittent equipment check
MANAGEMENT OF NEAR MISS
• POSTOPERATIVE
• High suspicious index
• Close monitoring of patient
• Proper documentation of critical events
• Proper communication of critical events
• Review of critical events
MANAGEMENT OF NEAR MISS
• ICU
• Knowledge of the pathology
• Daily equipment check
• Training and retraining of staff
• Equipment maintenance
• Proper documentation of critical events
• Proper communication of critical events
• Review of critical events
LITERATURE
REVIEW
Agbamu PO,Menkiti ID,Ohuoba IE.Desalu.Critical incidents and near
misses during anaesthesia :A prospective audit J Clin Sci 2017;14:18-
24

BACKGROUND
• Critical incident is any preventable mishap
• Patients safety can be improved by learning from reported critical incidents.
AIM
• To identify the incidence and potential risk factors leading to critical incidents
Agbamu PO,Menkiti ID,Ohuoba IE.Desalu.Critical incidents and near
misses during anaesthesia :A prospective audit J Clin Sci 2017;14:18-
24

• METHODS
• All critical incidents over a period of five months were prospectively
documented in critical incident reporting form
• Prior to data collection, audit was explained to all anaesthetists
• They were encouraged to document all critical incidents and near misses and no
punitive measure will be taken against them.
Agbamu PO,Menkiti ID,Ohuoba IE.Desalu.Critical incidents and near
misses during anaesthesia :A prospective audit J Clin Sci 2017;14:18-
24
Agbamu PO,Menkiti ID,Ohuoba IE.Desalu.Critical incidents and near
misses during anaesthesia :A prospective audit J Clin Sci 2017;14:18-
24
Agbamu PO,Menkiti ID,Ohuoba IE.Desalu.Critical incidents and near
misses during anaesthesia :A prospective audit J Clin Sci 2017;14:18-
24
Agbamu PO,Menkiti ID,Ohuoba IE.Desalu.Critical incidents and near
misses during anaesthesia :A prospective audit J Clin Sci 2017;14:18-
24
Agbamu PO,Menkiti ID,Ohuoba IE.Desalu.Critical incidents and near
misses during anaesthesia :A prospective audit J Clin Sci 2017;14:18-
24
Agbamu PO,Menkiti ID,Ohuoba IE.Desalu.Critical incidents and near
misses during anaesthesia :A prospective audit J Clin Sci 2017;14:18-
24

CONCLUSION
• Critical incident and near misses occur can occur in the hands of highly skilled
and in the presence of adequate monitoring
• Policies and protocol should be put in place to avoid errors
• Near misses and critical incidents should be documented in a blame free culture
to improve patients safety
Dias R,Dave N,Chiluveru S,Garasia M.Critical incidents in paediatric
anaesthesia:A prospective analysisover a 1 year period.aindia J
Anaesth 2016;60:801-806
• BACKGROUND
• Critical incident reporting id important as this helps to identify mistakes and
creates preventive measures in averting them.
• Many countries have such reporting systems.
• AIM
• To study the incidence of critical events in paediatric operating theatre.
Dias R,Dave N,Chiluveru S,Garasia M.Critical incidents in paediatric
anaesthesia:A prospective analysisover a 1 year period.aindia J
Anaesth 2016;60:801-806

• METHODS
• One year prospective observational study
• All children aged fifteen years and below receiving anaesthetic procedures were
included
• Surgeries performed include thoracic, lymph node biopsy,circumsicion,dressing
under general anaesthesia, abdominal surgeries, genitourinary surgeries were
performed.
• Pre-anaesthesia form was duly cross checked by consultant Anaesthetist and
child was well examined.
Dias R,Dave N,Chiluveru S,Garasia M.Critical incidents in paediatric
anaesthesia:A prospective analysisover a 1 year period.aindia J
Anaesth 2016;60:801-806

• Intraoperatively
• Children were monitored by same consultant
• End-tidal carbondioxide,non-invasive blood pressure monitoring, oxygen
saturation,temeparture and pulse rate were monitored.
• A register for critical incident was kept in the theatre
• Critical incidents were managed by the standard protocol for their operating
theatre.
• Postoperatively,
• Patients were monitored in the PACU by a third year Resident posted there for 2
hours
Dias R,Dave N,Chiluveru S,Garasia M.Critical incidents in paediatric
anaesthesia:A prospective analysisover a 1 year period.aindia J
Anaesth 2016;60:801-806

• RESULTS
• 1206 received anasethesia
• 105(8.7%) were neonates
• 227(18.8%) were infants
• 317(26.2%) were toddlers
• 557(46.1%) were older children
• 108 critical events were recorded
INCIDENT PERCENTAGE EXAMPLE

CLINICAL ASSESSMENT 4 (4.3%) -A cardiac murmur was

missed by a Senior resident.
-Nil hematological results

DOCUMENTATION OF 2 (1.8%) A patient results were filed in

EVENTS a different case note,
checklist not read before
induction

EQUIPMENT RELATED 2 (2.7%) Anaesthesia machine/monitor

suddenly shutdown

MEDICATION RELATED 4 (3.4%) Wrong medications, chest

wall rigidity from fentanyl,
bronchospasm from
gelufusine

AIRWAY AND 60 (55.5%) Laryngospasm,SADs,diff-

RESPIRATORY EVENTS icult airway, hypercarbia
INCIDENT PERCENTAGE EXAMPLE

CARDIOVASCULAR 12(11.1%) Atrial premature complexes,

ventricular bigeminy,
bradycardia during CVC
insertion, vessel injury during
surgery

REGIONAL RELATED 5 (4.6%) Accidental epidural removal,

Dural puncture

Communication related 1(0.9%) Mother breasted child despite

fasting order

MICELLANOUS 17(15.7%) IV disconnection, cautery

burn, unable to vocalize.
Dias R,Dave N,Chiluveru S,Garasia M.Critical incidents in paediatric
anaesthesia:A prospective analysisover a 1 year period.aindia J
Anaesth 2016;60:801-806

CONCLUSION
• Critical incidents reporting creates an avenue to increase and improve
perioperative safety in children.
• As Anaesthetic physicians, proper documentation is important.
THANK YOU FOR
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