On 23 February, two-year-old Maxime underwent surgery for an umbilical hernia. He had no pre-existing medical conditions but was suffering from a severe cough prior to the operation. The operation went smoothly, but during transfer the patient unexpectedly developed acute pulmonary oedema. During the management of this complication, the team is confronted with a second adverse event: while medication was being administered, the rate of infusion was set wrongly, which resulted in severe fluid overload, hyperglycaemia and major lactic acidosis. A review of this adverse event highlighted three strands of analysis: the importance of airway management in children; team communication in crisis situations; and adapting the environment and materials to the specific context (paediatrics).
Date de parution : 09/2017
Thème : Surgery
Mots clés : Pediatrics, Crisis management, risk
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