RESUMO
An optical surgical navigation system is used as a navigator to facilitate surgical approaches, and pulse oximeters provide valuable information for anesthetic management. However, saw-tooth waves on the monitor of a pulse oximeter and the inability of the pulse oximeter to accurately record the saturation of a percutaneous artery were observed when a surgeon started an optical navigation system. The current case is thought to be the first report of this navigation system interfering with pulse oximetry. The causes of pulse jamming and how to manage an optical navigation system are discussed.
RESUMO
BACKGROUND: The anesthetic incident-reporting scheme in the department of anesthesia, Jichi Medical School Hospital, has been running for 3 years and 100 incidents have now been reported. METHODS: An 'anesthetic incident' was defined as any incident related to anesthesia which either caused harm, or if uncorrected might have caused harm, to a patient. RESULTS: There were 26 problems involving drugs, 18 airway and respiratory problems, 15 dental damages, 11 cardiovascular problems, 8 problems related epidural anesthesia, and 22 others. CONCLUSIONS: The scheme has successfully highlighted weaknesses of the department.