oa Southern African Journal of Anaesthesia and Analgesia - Anaesthetic accidents : an experience in sub-saharan Africa : case report

Volume 12, Issue 3
  • ISSN : 2220-1181
  • E-ISSN: 2220-1173



Anaesthetic accidents as a cause of morbidity and mortality are beginning to cause great concern in developing countries, where there is still a dearth of reporting of critical incidents. A case of a 55-year-old Nigerian woman who developed signs of cerebral hypoxia following osteotomy under general anaesthesia delivered through a draw-over Portable Anaesthetic Circuit (PAC) unit is reported. She was resuscitated and had intensive care therapy following this critical incident. This case highlights human error, and possibly technical failure as predisposing factors leading to anaesthetic accidents. It also emphasizes the need for anaesthetists to address safety issues more seriously. Reported critical incidents in our operating rooms should be audited, analysed and discussed in departmental quality assurance meetings, in order to indicate the potential causes and management of those incidents that are attributable to anaesthesia. A multi-disciplinary approach to the management of critical incidents is advocated to prevent future occurrences.

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