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Near Misses in Neuroanesthesia

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Textbook of Neuroanesthesia and Neurocritical Care

Abstract

A near miss in healthcare is defined as an unplanned, preventable event that can potentially cause physical or psychological harm to a patient and/or physician. Preventable errors have significant human and financial costs. These adverse events offer unique learning opportunities—understanding the causes of preventable errors is crucial to preventing them from happening again. It is important to recognize that near misses differ from recognized patient complications; patients are counselled about potential complications as part of the consent to treatment. In this chapter, we approach the subject of near misses using the airway-breathing-circulation (ABC) method familiar to healthcare professionals worldwide and suggest management strategies to avoid these preventable errors.

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References

  1. Barach P, Small SD. Reporting and preventing medical mishaps: lessons from non-medical near miss reporting systems. BMJ. 2000;320(7237):759–63.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  2. Lipshutz AK, Caldwell JE, Robinowitz DL, Gropper MA. An analysis of near misses identified by anesthesia providers in the intensive care unit. BMC Anesthesiol. 2015;15(1):93.

    Article  PubMed  PubMed Central  Google Scholar 

  3. Nimmagadda U, Salem MR, Crystal GJ. Preoxygenation: physiologic basis, benefits, and potential risks. Anesth Analg. 2017;124(2):507–17.

    Article  CAS  PubMed  Google Scholar 

  4. Raphael J, Rosenthal-Ganon T, Gozal Y. Emergency airway management with a laryngeal mask airway in a patient placed in the prone position. J Clin Anesth. 2004;16(7):560–1.

    Article  PubMed  Google Scholar 

  5. McCredie VA, Ferguson ND, Pinto RL, Adhikari NK, Fowler RA, Chapman MG, et al. Airway management strategies for brain-injured patients meeting standard criteria to consider extubation. a prospective cohort study. Ann Am Thorac Soc. 2017;14(1):85–93.

    Article  PubMed  Google Scholar 

  6. Coplin WM, Pierson DJ, Cooley KD, Newell DW, Rubenfeld GD. Implications of extubation delay in brain-injured patients meeting standard weaning criteria. Am J Respir Crit Care Med. 2000;161(5):1530–6.

    Article  CAS  PubMed  Google Scholar 

  7. Bruder NJ. Awakening management after neurosurgery for intracranial tumours. Curr Opin Anaesthesiol. 2002;15(5):477–82.

    Article  PubMed  Google Scholar 

  8. Cormack J, Karna S. Macroglossia during awake craniotomy: a near miss. J Neurosurg Anesthesiol. 2017;30(4):383–4.

    Google Scholar 

  9. Lam AM, Vavilala MS. Macroglossia: compartment syndrome of the tongue? Anesthesiology. 2000;92(6):1832–5.

    Article  CAS  PubMed  Google Scholar 

  10. Brockerville M, Venkatraghavan L, Manninen P. Macroglossia in neurosurgery. J Neuroanaesth Crit Care. 2017;4(2):78–84.

    Article  Google Scholar 

  11. Moore JK, Chaudhri S, Moore AP, Easton J. Macroglossia and posterior fossa disease. Anaesthesia. 1988;43(5):382–5.

    Article  CAS  PubMed  Google Scholar 

  12. Pivalizza EG, Katz J, Singh S, Liu W, McGraw-Wall BL. Massive macroglossia after posterior fossa surgery in the prone position. J Neurosurg Anesthesiol. 1998;10(1):34–6.

    Article  CAS  PubMed  Google Scholar 

  13. Sinha A, Agarwal A, Gaur A, Pandey CK. Oropharyngeal swelling and macroglossia after cervical spine surgery in the prone position. J Neurosurg Anesthesiol. 2001;13(3):237–9.

    Article  CAS  PubMed  Google Scholar 

  14. Schnell D, Planquette B, Berger A, Merceron S, Mayaux J, Strasbach L, et al. Cuff leak test for the diagnosis of post-extubation stridor. J Intensive Care Med. 2017;0(0):885066617700095.

    Google Scholar 

  15. Maury E, Guglielminotti J, Alzieu M, Qureshi T, Guidet B, Offenstadt G. How to identify patients with no risk for postextubation stridor? J Crit Care. 2004;19(1):23–8.

    Article  PubMed  Google Scholar 

  16. Sandhu RS, Pasquale MD, Miller K, Wasser TE. Measurement of endotracheal tube cuff leak to predict postextubation stridor and need for reintubation. J Am Coll Surg. 2000;190(6):682–7.

    Article  CAS  PubMed  Google Scholar 

  17. De Bast Y, De Backer D, Moraine JJ, Lemaire M, Vandenborght C, Vincent JL. The cuff leak test to predict failure of tracheal extubation for laryngeal edema. Intensive Care Med. 2002;28(9):1267–72.

    Article  PubMed  Google Scholar 

  18. Haller JM, Iwanik M, Shen FH. Clinically relevant anatomy of recurrent laryngeal nerve. Spine (Phila Pa 1976). 2012;37(2):97–100.

    Article  Google Scholar 

  19. Manski TJ, Wood MD, Dunsker SB. Bilateral vocal cord paralysis following anterior cervical discectomy and fusion. Case Rep J Neurosurg. 1998;89(5):839–43.

    CAS  Google Scholar 

  20. Bertalanffy H, Eggert HR. Complications of anterior cervical discectomy without fusion in 450 consecutive patients. Acta Neurochir. 1989;99(1–2):41–50.

    Article  CAS  PubMed  Google Scholar 

  21. Bulger RF, Rejowski JE, Beatty RA. Vocal cord paralysis associated with anterior cervical fusion: considerations for prevention and treatment. J Neurosurg. 1985;62(5):657–61.

    Article  CAS  PubMed  Google Scholar 

  22. Cloward RB. New method of diagnosis and treatment of cervical disc disease. Clin Neurosurg. 1962;8:93–132.

    Article  CAS  PubMed  Google Scholar 

  23. Erwood MS, Hadley MN, Gordon AS, Carroll WR, Agee BS, Walters BC. Recurrent laryngeal nerve injury following reoperative anterior cervical discectomy and fusion: a meta-analysis. J Neurosurg Spine. 2016;25(2):198–204.

    Article  PubMed  Google Scholar 

  24. Tan TP, Govindarajulu AP, Massicotte EM, Venkatraghavan L. Vocal cord palsy after anterior cervical spine surgery: a qualitative systematic review. Spine J. 2014;14(7):1332–42.

    Article  PubMed  Google Scholar 

  25. Pattavilakom A, Seex KA. Comparison of retraction pressure between novel and conventional retractor systems--a cadaver study. J Neurosurg Spine. 2010;12(5):552–9.

    Article  PubMed  Google Scholar 

  26. Sperry RJ, Johnson JO, Apfelbaum RI. Endotracheal tube cuff pressure increases significantly during anterior cervical fusion with the Caspar instrumentation system. Anesth Analg. 1993;76(6):1318–21.

    Article  CAS  PubMed  Google Scholar 

  27. Audu P, Artz G, Scheid S, Harrop J, Albert T, Vaccaro A, et al. Recurrent laryngeal nerve palsy after anterior cervical spine surgery: the impact of endotracheal tube cuff deflation, reinflation, and pressure adjustment. Anesthesiology. 2006;105(5):898–901.

    Article  PubMed  Google Scholar 

  28. Pisanu A, Porceddu G, Podda M, Cois A, Uccheddu A. Systematic review with meta-analysis of studies comparing intraoperative neuromonitoring of recurrent laryngeal nerves versus visualization alone during thyroidectomy. J Surg Res. 2014;188(1):152–61.

    Article  PubMed  Google Scholar 

  29. Hachwa B, Halim-Armanios M. Bilateral vocal cord injury following anterior cervical discectomy: could a better preoperative exam have prevented it? Libyan J Med. 2006;1(2):156–61.

    Article  PubMed  PubMed Central  Google Scholar 

  30. Toyota S, Amaki Y. Hemodynamic evaluation of the prone position by transesophageal echocardiography. J Clin Anesth. 1998;10(1):32–5.

    Article  CAS  PubMed  Google Scholar 

  31. Dharmavaram S, Jellish WS, Nockels RP, Shea J, Mehmood R, Ghanayem A, et al. Effect of prone positioning systems on hemodynamic and cardiac function during lumbar spine surgery: an echocardiographic study. Spine (Phila Pa 1976). 2006;31(12):1388–93. discussion 94.

    Article  Google Scholar 

  32. Penfield W, McNaughton F. Dural headache and innervation of the dura mater. Arch Neurol Psychiatr. 1940;44(1):43–75.

    Article  Google Scholar 

  33. Vimala S, Arulvelan A. Sudden bradycardia and hypotension in neurosurgery: trigeminocardiac reflex (TCR) and more. J Neurosurg Anesthesiol. 2016;28(2):175–6.

    Article  PubMed  Google Scholar 

  34. Agrawal A, Timothy J, Cincu R, Agarwal T, Waghmare LB. Bradycardia in neurosurgery. Clin Neurol Neurosurg. 2008;110(4):321–7.

    Article  PubMed  Google Scholar 

  35. Schaller B. Trigemino-cardiac reflex during transsphenoidal surgery for pituitary adenomas. Clin Neurol Neurosurg. 2005;107(6):468–74.

    Article  PubMed  Google Scholar 

  36. Michard F. Changes in arterial pressure during mechanical ventilation. Anesthesiology. 2005;103(2):419–28. quiz 49–5.

    Article  PubMed  Google Scholar 

  37. Biais M, Bernard O, Ha JC, Degryse C, Sztark F. Abilities of pulse pressure variations and stroke volume variations to predict fluid responsiveness in prone position during scoliosis surgery. Br J Anaesth. 2010;104(4):407–13.

    Article  CAS  PubMed  Google Scholar 

  38. Chigurupati K, Vemuri NN, Velivela SR, Mastan SS, Thotakura AK. Topical lidocaine to suppress trigemino-cardiac reflex. Br J Anaesth. 2013;110(1):145.

    Article  CAS  PubMed  Google Scholar 

  39. Chowdhury T, Mendelowith D, Golanov E, Spiriev T, Arasho B, Sandu N, et al. Trigeminocardiac reflex: the current clinical and physiological knowledge. J Neurosurg Anesthesiol. 2015;27(2):136–47.

    Article  PubMed  Google Scholar 

  40. Saladino A, Lamperti M, Mangraviti A, Legnani FG, Prada FU, Casali C, et al. The semisitting position: analysis of the risks and surgical outcomes in a contemporary series of 425 adult patients undergoing cranial surgery. J Neurosurg. 2017;127(4):867–76.

    Article  PubMed  Google Scholar 

  41. Himes BT, Mallory GW, Abcejo AS, Pasternak J, Atkinson JLD, Meyer FB, et al. Contemporary analysis of the intraoperative and perioperative complications of neurosurgical procedures performed in the sitting position. J Neurosurg. 2017;127(1):182–8.

    Article  PubMed  Google Scholar 

  42. Toung TJ, Rossberg MI, Hutchins GM. Volume of air in a lethal venous air embolism. Anesthesiology. 2001;94(2):360–1.

    Article  CAS  PubMed  Google Scholar 

  43. Hagen PT, Scholz DG, Edwards WD. Incidence and size of patent foramen ovale during the first 10 decades of life: an autopsy study of 965 normal hearts. Mayo Clin Proc. 1984;59(1):17–20.

    Article  CAS  PubMed  Google Scholar 

  44. Jadik S, Wissing H, Friedrich K, Beck J, Seifert V, Raabe A. A standardized protocol for the prevention of clinically relevant venous air embolism during neurosurgical interventions in the semisitting position. Neurosurgery. 2009;64(3):533–8. discussion 8–9.

    Article  PubMed  Google Scholar 

  45. Laban JT, Rasul FT, Brecker SJ, Marsh HT, Martin AJ. Patent foramen ovale closure prior to surgery in the sitting position. Br J Neurosurg. 2014;28(3):421–2.

    Article  PubMed  Google Scholar 

  46. Guldiken B, Remi J, Noachtar S. Cardiovascular adverse effects of phenytoin. J Neurol. 2016;263(5):861–70.

    Article  CAS  PubMed  Google Scholar 

  47. Franco V, Perucca E. CYP2C9 polymorphisms and phenytoin metabolism: implications for adverse effects. Expert Opin Drug Metab Toxicol. 2015;11(8):1269–79.

    Article  CAS  PubMed  Google Scholar 

  48. Weston J, Greenhalgh J, Marson AG. Antiepileptic drugs as prophylaxis for post-craniotomy seizures. Cochrane Database Syst Rev. 2015;3:CD007286.

    Google Scholar 

  49. Carney N, Totten AM, O’Reilly C, Ullman JS, Hawryluk GW, Bell MJ, et al. Guidelines for the management of severe traumatic brain injury, Fourth Edition. Neurosurgery. 2017;80(1):6–15.

    PubMed  Google Scholar 

  50. Kamel H, Navi BB, Nakagawa K, Hemphill JC 3rd, Ko NU. Hypertonic saline versus mannitol for the treatment of elevated intracranial pressure: a meta-analysis of randomized clinical trials. Crit Care Med. 2011;39(3):554–9.

    Article  CAS  PubMed  Google Scholar 

  51. Mortazavi MM, Romeo AK, Deep A, Griessenauer CJ, Shoja MM, Tubbs RS, et al. Hypertonic saline for treating raised intracranial pressure: literature review with meta-analysis. J Neurosurg. 2012;116(1):210–21.

    Article  PubMed  Google Scholar 

  52. Prabhakar H, Singh GP, Anand V, Kalaivani M. Mannitol versus hypertonic saline for brain relaxation in patients undergoing craniotomy. Cochrane Database Syst Rev. 2014;7:CD010026.

    Google Scholar 

  53. Elliott CA, MacKenzie M, O’Kelly CJ. Mannitol dosing error during interfacility transfer for intracranial emergencies. J Neurosurg. 2015;123(5):1166–9.

    Article  CAS  PubMed  Google Scholar 

  54. Chang SH, Miller NR. The incidence of vision loss due to perioperative ischemic optic neuropathy associated with spine surgery: the Johns Hopkins Hospital Experience. Spine (Phila Pa 1976). 2005;30(11):1299–302.

    Article  Google Scholar 

  55. Lee LA, Roth S, Posner KL, Cheney FW, Caplan RA, Newman NJ, et al. The American Society of Anesthesiologists Postoperative Visual Loss Registry: analysis of 93 spine surgery cases with postoperative visual loss. Anesthesiology. 2006;105(4):652–9. quiz 867–8.

    Article  PubMed  Google Scholar 

  56. Myers MA, Hamilton SR, Bogosian AJ, Smith CH, Wagner TA. Visual loss as a complication of spine surgery. A review of 37 cases. Spine (Phila Pa 1976). 1997;22(12):1325–9.

    Article  CAS  Google Scholar 

  57. Kwee MM, Ho YH, Rozen WM. The prone position during surgery and its complications: a systematic review and evidence-based guidelines. Int Surg. 2015;100(2):292–303.

    Article  PubMed  PubMed Central  Google Scholar 

  58. Roth S. Perioperative visual loss: what do we know, what can we do? Br J Anaesth. 2009;103(Suppl 1):i31–40.

    Article  PubMed  PubMed Central  Google Scholar 

  59. Tempelhoff R. An optic nerve at risk and a prolonged surgery in the prone position: time to reconsider? Anesthesiology. 2008;108(5):775–6.

    Article  PubMed  Google Scholar 

  60. Postoperative Visual Loss Study Group. Risk factors associated with ischemic optic neuropathy after spinal fusion surgery. Anesthesiology. 2012;116(1):15–24.

    Google Scholar 

  61. American Society of Anesthesiologists Task Force on Perioperative Visual Loss. Practice advisory for perioperative visual loss associated with spine surgery: an updated report by the American Society of Anesthesiologists Task Force on Perioperative Visual Loss. Anesthesiology. 2012;116(2):274–85.

    Article  Google Scholar 

  62. Mirovsky Y, Neuwirth M. Injuries to the lateral femoral cutaneous nerve during spine surgery. Spine (Phila Pa 1976). 2000;25(10):1266–9.

    Article  CAS  Google Scholar 

  63. Goettler CE, Pryor JP, Reilly PM. Brachial plexopathy after prone positioning. Crit Care. 2002;6(6):540–2.

    Article  PubMed  PubMed Central  Google Scholar 

  64. Schwartz DM, Drummond DS, Hahn M, Ecker ML, Dormans JP. Prevention of positional brachial plexopathy during surgical correction of scoliosis. J Spinal Disord. 2000;13(2):178–82.

    Article  CAS  PubMed  Google Scholar 

  65. Mobley SR, Miller BT, Astor FC, Fine B, Halliday NJ. Prone positioning for head and neck reconstructive surgery. Head Neck. 2007;29(11):1041–5.

    Article  PubMed  Google Scholar 

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Authors and Affiliations

  1. Department of Anesthesia, University Health Network, Toronto Western Hospital, Toronto, ON, Canada

    Zakir Hajat & Zoe Unger

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  1. Zakir Hajat
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  2. Zoe Unger
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Editors and Affiliations

  1. Department of Neuroanaesthesiology and Critical Care, All India Institute of Medical Sciences, New Delhi, India

    Hemanshu Prabhakar

  2. Division of Neuroanesthesiology, Department of Anesthesiology, Sher-i-Kashmir Institute of Medical Sciences Soura, Srinagar, Jammu and Kashmir, India

    Zulfiqar Ali

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Hajat, Z., Unger, Z. (2019). Near Misses in Neuroanesthesia. In: Prabhakar, H., Ali, Z. (eds) Textbook of Neuroanesthesia and Neurocritical Care. Springer, Singapore. https://doi.org/10.1007/978-981-13-3387-3_28

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  • DOI: https://doi.org/10.1007/978-981-13-3387-3_28

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