Page 38 - 2022 Risk Basics - Anesthesiology

SVMIC Risk Basics: Anesthesiology

CASE STUDY

A more specific case example involved an anesthesiologist
who prepared a morphine bolus to be given by epidural
catheter for postoperative pain control in an 11-month-old.

He was then called out of the room, leaving the CRNA to
oversee the infusion. The morphine infused in 20 minutes.

When the anesthesiologist returned, he realized that the

timing of the pump had been set inaccurately as he had
intended to give a small dose over a short period of time

followed by a larger dose over a 24-hour period. There had
been no communication of this plan to the CRNA and no

notation of this in the anesthesia plan. Thus, it appeared
that the CRNA gave too much volume of morphine

anesthetic into the spinal cord of the 11-month-old baby

with a devastating result. The baby was unable to move
his legs postoperatively.

Good communication between the anesthesiologist and the

CRNA is extremely important and should be documented.
Some suggestions to ensure good communication are:

 Review the pre-anesthesia evaluation and communicate

with the CRNA regarding the anesthesia plan

 Ensure that you, the anesthesiologist, are present in the

OR upon induction, key portions of the procedure, as well

as emergence

 Insist that CRNAs communicate to you immediately

regarding all unusual events and readings

 Be approachable

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