Denosumab-induced autoimmune hepatitis: Case report.

This report described a patient not known to have a hepatic disease, found to have a drug-induced autoimmune hepatitis from denosumab. This is an unreported side effect, and here, we presented the possible predisposing factors and suggested monitoring parameters.

Sickle Cell Disease Phenotypes and Obstructive Sleep Apnea; Are They Related?

OBJECTIVE: This study aims to compare the polysomnographic features between Arab-Indian and Benin phenotypes of sickle cell disease (SCD). MATERIALS AND METHODS: This prospective cross-sectional study was conducted in the Children's Hospital at King Fahad MedicalCity, in Riyadhwhere childrenwere recruited fromthe pediatric hematology clinic and pediatric sleepmedicine. All families were approached and patients who met the inclusion criteria and agreed to participate were included in the study. RESULTS: Eighty four children (37 of whom were females) with SCD were included in the study. Their median (interquartile) age was 9 (6.65, 11) years and their body mass index z score was -1.45 (-2.195, -1.45). The evidence of obstructive sleep apnea (OSA) was more prominent in the Benin phenotype (66.7%) in comparison to those of the Arab-Indian (35.2%) phenotype ( p = 0.006). Additionally, 56.7% of Benin had moderate to severe OSA whereas Arab-Indian had 18% with a ( p = 0.0003). Controlling for other factors, the odds ratio (confidence interval) of having OSA in Benin phenotype was 4.68 (1.42-15.38) times higher as compared to Arab-Indian phenotype. CONCLUSION: The risk of having OSA as well as the severity of OSA is higher in Benin phenotype as compared to Arab-Indian phenotype which indicates the presence of potential OSA risk factors other than the SCD itself.

Charlson Comorbidity Index as a Predictor of Difficult Cholecystectomy in Patients With Acute Cholecystitis.

Background The Charlson Comorbidity Index (CCI) has been validated as a predictor of overall survival and post-surgical mortality. CCI is adopted by Tokyo Guidelines as one of the main criteria in the management of acute cholecystitis. Our study evaluates the role of CCI in predicting difficult cholecystectomy.  Methods All patients who underwent cholecystectomy for acute cholecystitis between January 2017 and September 2019 were included. CCI, Emergency Surgery Score (ESS), and American Society of Anesthesiologists (ASA) score were calculated and analyzed to assess their predictive value for difficult cholecystectomy. Results A total of 96 patients were included and allocated to difficult and non-difficult cholecystectomy groups. CCI was found to be a significant predictor of difficult cholecystectomy (OR 1.59; 59% CI, 1.04. 2.42; p= 0.031). Similarly, ESS was found to be a predictor tool of difficult cholecystectomy (OR 1.42; 59% CI, 1.05. 1.93; p= 0.024). There was no significant difference in adverse outcomes between the two groups. Conclusion CCI was able to predict a difficult cholecystectomy in our study population. However further studies are required to evaluate if it can be used as a predictor of adverse outcomes in the context of acute cholecystitis.

Severe asthma in children: An official statement from Saudi Pediatric Pulmonology Association.

In Saudi Arabia, the prevalence of pediatric asthma ranges between 8% and 25%. However, there are no sufficient data regarding severe asthma in childhood in Saudi Arabia. Therefore, a task force has been formed by the Saudi Pediatric Pulmonology Association which is a subsidiary group of the Saudi Thoracic Society and consists of Saudi experts with well-respected academic and clinical backgrounds in the fields of pediatric asthma as well as other respiratory diseases to write a consensus on definitions, phenotypes, and pathophysiology, evaluation, and management. To achieve this, the subject was divided into various sections, each of which was assigned to at least 2 experts. Without a central literature review, the authors searched the literature using their own strategies. To reach an agreement, the entire panel reviewed and voted on proposed findings and recommendations.

Hemorrhagic Necrotizing Cholecystitis With Cholecystocolonic Fistula: A Case Report.

Cholecystocolonic fistula (CCF) and hemorrhagic cholecystitis are rare complications of gallstones that have a wide range of non-specific symptoms and clinical severity. We present a case of a 74-year-old woman on warfarin who presented to the emergency department with a 10-day history of abdominal pain, vomiting, and watery diarrhea. Her abdomen was distended with generalized tenderness and palpable mass in the right lower quadrant. Laboratory tests revealed leukocytosis and an elevated international normalized ratio (INR). After admission and imaging, exploratory laparotomy showed hemorrhagic cholecystitis with CCF in the cecum. There was no pus or stool contamination. A cholecystectomy followed by right hemicolectomy with primary ileocolic anastomosis was performed. The postoperative course was uneventful, and the patient was discharged in stable condition. The presence of hemorrhagic cholecystitis in conjunction with CCF could lead to significant consequences such as hemorrhagic and septic shock in older patients with comorbidities. It is crucial to identify and intervene early before clinical deterioration.

Clinical and molecular characteristics of primary ciliary dyskinesia: A tertiary care centre experience.

BACKGROUND: Primary ciliary dyskinesia (PCD) is a ciliopathy with diverse clinical and genetic findings caused by abnormal motile cilia structure and function. In this study, we describe the clinical characteristics of confirmed PCD cases in our population and report the radiological, genetic, and laboratory findings. METHODS: This was a retrospective, observational, single-centre study. We enrolled 18 patients who were diagnosed with confirmed PCD between 2015 and 2019. We then analyzed their data, including clinical findings and workup. RESULTS: In our cohort, 56% of patients had molecularly confirmed PCD, and RSPH9 was the most common gene identified. Transmission electron microscopy (TEM) showed an ultrastructural defect in 64% of samples, all of which matched the genetic background of the patient. Situs inversus (SI) was observed in 50% of patients, and congenital heart disease was observed in 33%. The median body mass index (BMI) was 15.87 kg/m2, with a median z score of -1.48. The median FEV1 value was 67.6% (z score - 2.43). Radiologically, bronchiectasis was noted in 81% of patients at a variable degree of severity. Lung bases were involved in 91% of patients. We were unable to correlate the genotype-phenotype findings. CONCLUSION: We describe the clinical and molecular characteristics of patients with confirmed PCD in a tertiary centre in Saudi Arabia and report 9 new pathogenic or likely pathogenic variants in one of the PCD-associated genes.

The attitude and practice of general surgeons toward cytoreductive surgery and hyperthermic intraperitoneal chemotherapy: A cross-sectional study.

BACKGROUND: Cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC) mandate well-established HIPEC and oncology centers, which are not available in many medical institutions. This study assessed the knowledge, attitude, and practice toward CRS and HIPEC of general surgeons in Riyadh, Saudi Arabia. PATIENTS AND METHODS: General surgeons (n = 266) from nine hospitals who treat patients with gastrointestinal cancer were surveyed. The responses of surgeons who work in HIPEC and academic centers (Group A) and surgeons working in tertiary and secondary hospitals (Group B) were compared. The survey response rate was 48.1% (128/266). RESULTS: Surgeons in group B treated significantly more patients with peritoneal carcinomatosis per year than surgeons in group A (P = .001). Group B reported having a HIPEC specialist at their hospital, and 71.4% reported that the nearest HIPEC center was within 30 miles, compared to 4.5% of respondents in group A (P = .001). Lack of access to a HIPEC specialist was reported by 15.5% of surgeons in group B and 0% of surgeons in group A (P = .006). HIPEC as a possible therapeutic option for appendiceal cancer was cited by 60.7% of surgeons in group B compared to 84.1% of surgeons in group A (P = .007) and as a therapeutic option for ovarian cancer by 52.4% of surgeons in group B and 81.8% of surgeons in group A (P = .001). CONCLUSION: New strategies are needed to improve the knowledge and implementation of the referral system for HIPEC among general surgeons. Our study was limited by a low response rate.

Cystic Ovarian Leiomyoma in a Patient with Progressive Abdominal Pain.

BACKGROUND Ovarian leiomyomas are rare, benign, smooth muscle, solid tumors that occur in women aged 20 to 65 years. Because their histology is benign, the prognosis for patients is good. We report the case of a patient with a huge ovarian leiomyoma who presented to the General Surgery Clinic with chronic abdominal pain and progressive abdominal distention. CASE REPORT A 45-year-old woman with a history of multiple myomectomies and a total abdominal hysterectomy with right oophorectomy presented to the General Surgery Clinic with abdominal pain and a 4-year history of progressive distention. After being examined, the patient underwent an exploratory laparotomy, during which a pelvic cyst was found that measured 3930.2 cm, was filled with serous fluid (10.5 L), and occupied most of the abdominal space. The surgery went smoothly and there were no complications during or after the procedure. The patient was discharged home 7 days later in stable condition. Postoperative pathology using hematoxylin and eosin staining and immunohistochemistry with desmin and alpha-smooth muscle actin resulted in a diagnosis of leiomyoma with cystic degeneration. When the patient was seen in the outpatient clinic 2 weeks and 3 and 6 months after surgery, her tumor markers were within normal limits. Abdominal and pelvic computed tomography scans performed at the 6-month visit showed resolution of the loculated intraperitoneal fluid and no gross local recurrence of the tumor. CONCLUSIONS Ovarian leiomyomas are difficult to diagnose preoperatively. Suspicion for one should be high, however, in patients who present with a large cystic mass in adnexal tissues, especially if they have a history of hysterectomy and oophorectomy.

Pediatric gastropleural fistula, a complication of sleeve gastrectomy: Case report and brief review.

Gastropleural fistula (GPF) is a rare pathological communication between the stomach and pleura. It may complicate sleeve gastrectomy (SG). An endoscopic application of OTSC can be used to manage GPF.

An SFTPC gene mutation causes childhood interstitial lung disease: first report in the Arab region.

BACKGROUND: Surfactant protein C dysfunction is one of the causes of childhood interstitial lung disease but has not previously been reported in Arabian countries. CASE PRESENTATION: A six-year-old girl had presented at the age of eight months old with bronchiolitis followed by a persistent cough, dyspnea and hypoxaemia. She was found to have gastroesophageal reflux disease, but her symptoms did not resolve despite her therapy being optimised. Further tests, including a chest computed tomographic scan, lung biopsy and genetic testing, confirmed a diagnosis of surfactant protein C dysfunction. CONCLUSION: We report the first case in the Arab region of childhood interstitial lung disease caused by surfactant protein C deficiency.

Association between cigarette & shisha smoking and the severity of polycythemia: A cross sectional study.

Tobacco cigarette smoking is assumed to be a key reason of death all over the world. Smoking had both severe as well long-lasting effects on hematological constraints. As per the data available from World Health Organization, every year nearly 5 million individuals die around the world due to the diseases triggered by smoking. Cigarette smoking is linked with an elevated risk of cardiovascular diseases. To examine the association between shisha or cigarette smoking and the severity of polycythemia, present study is a cross-sectional organized at King Saud University Medical City during the period from October 2017 to April 2018. Participants were patients who have hemoglobin level above 160 g/L on multiple reading in KSUMC between May 2015-February 2018. The sample size (227 patients) was computed on single proportion formula, Data were collected through questionnaires and from medical record of the patients. A pilot study was conducted to evaluate the validity of the questionnaire. A statistical analysis was performed using SPSS 21.0 version. A p-value of ≤ 0.05 considered as statistically significant. Out of 227 study subjects, 86 (37.8%) were smokers, (61.6%) were cigarette smokers while (29%), shisha smokers. Total (9.3%) were smoking both cigarette and Shisha. 29% patients had high normal hemoglobin between the ranges of (160-168 g/L), 17.6% patients had pre-polycythemic hemoglobin between the range of (169-171 g/L) and 53% patients were having polycythemic hemoglobin (>172 g/L). The hemoglobin level in non-smokers was 168.74 g/L, hemoglobin level in cigarette smokers was170.7 g/L, hemoglobin level in shisha smokers was 171.4 g/L while hemoglobin level in those who smokes both cigarette and shisha was 175 g/L. Smoking has adverse effects on hemoglobin. Shisha or cigarette Smoking is associated with increase in the hemoglobin levels and the severity of polycythemia. The findings may help in raising the awareness of tobacco smokers.

Anesthesia experience of pediatric robotic surgery in a University Hospital.

Robotic technology has a promising future in surgical field. Robotic-assisted laparoscopy is a newly advance technology which is highly accepted by most of surgeons in various surgical procedures. As the pediatric surgeons adopt and master robotic technique, anesthesiologists familiarized themselves with this technique as well. Robotic surgery required a high-quality of perioperative anesthesia care that is essential for optimizing surgical outcome and patient safety. A retrospective analysis of robotic-assisted surgery for all children under age of 18 years from June 2004 to November 2013 at King Khalid University Hospital was conducted. Data of demographic (age, sex, and weight), type of procedures, operative time, intraoperative and postoperative complications were noted. Seventy robot assisted laparoscopy procedures were performed using the da Vinci surgical system. All procedures except three cases were successfully completed using robot with mean operative time of 110 min. Nissen fundoplication (34 cases) was the commonest robotic surgical procedure performed followed by cholecystectomy, anal-pull through and gastric banding. There were no intraoperative and postoperative complications related to anesthesia. Robotic-assisted laparoscopy is a safe and feasible technique for a variety of pediatric procedures. Our findings suggest that, perioperative anesthesia care should be considered in advance with high anesthetic precautions to maximize patient safety and improve surgical outcome. It is worth to have more studies measuring clinical anesthesia outcome of pediatric robotic surgery.

Pediatric sickle cell disease and obstructive sleep apnea: A cross-sectional study in a tertiary pediatric center in Saudi Arabia.

OBJECTIVE: The aim of the study was to evaluate snoring and obstructive sleep apnea (OSA) in Saudi children with sickle cell disease (SCD). MATERIALS AND METHODS: This cross-sectional study was conducted among children with SCD attending a hematology clinic were recruited. Demographics, clinical data, and sleep questionnaires were collected and overnight polysomnographies performed. RESULTS: Seventy children (31 of whom were females) with SCD were included in the study. Their median (interquartile) age was 9 (6.5, 11) years and their body mass index z-score was -1.2 (-2.0, -0.4). Seventy-four percent of SCD patients snored and 32 (46%) had evidence of OSA (obstructive apnea-hypopnea index [OAHI] ≥2 events per hour of sleep), 13 of whom had moderate OSA (OAHI ≥5 and <10 events per hour of sleep) and 10 had severe OSA (OAHI ≥10 events per hour of sleep). CONCLUSION: Snoring and the proportion of OSA were high in children with SCD. This underlines the importance of screening for OSA in all children with SCD.

Intraoperative Nerve Stimulation During Brachial Plexus Surgery: Comparison Between a Totally Disposable Nerve Stimulator and Nerve Stimulator Normally Used for Nerve Blocks.

BACKGROUND: Intraoperative nerve stimulation is done routinely in brachial plexus and peripheral nerve surgery as well as in selective neurectomy in spastic patients. OBJECTIVE: The current study compares the use of 2 different devices for nerve stimulation: a totally disposable nerve stimulator and a nerve stimulator used for nerve blocks by anesthetists. METHODS: A retrospective study of 60 patients who underwent brachial plexus surgery: In 30 patients, we used the totally disposable nerve stimulator (group 1) and in another 30 patients, we used the anesthesia device (group 2). The cost of disposable materials used for nerve stimulation was calculated in each group. The same surgeon performed all operations, and he was asked to give his subjective opinion regarding the convenience and ease of use of the device in each group. RESULTS: The main advantages of the totally disposable device are its placement totally within the sterile field, and it is operated by the surgeon without the need to communicate with the anesthetist. However, the totally disposable device had several major disadvantages when compared to the anesthesia device. Firstly, the disposable stimulator can only deliver 0.5, 1.0, and 2.0 mA stimuli, while the anesthesia device can deliver stimuli of 0.1 to 5 mA (in 0.1 mA increments). Secondly, the disposable stimulator frequently fails to operate during surgery, and this is not experienced with the anesthesia device. Finally, the cost of disposables is less using the anesthesia device. CONCLUSION: Our center has stopped using the disposable nerve stimulator in favour for the anesthesia device.

HISTORIQUE: La stimulation nerveuse intraopératoire est utilisée régulièrement lors d'opérations du plexus brachial et des nerfs périphériques, de même que lors de neurectomies sélectives chez les patients spastiques. OBJECTIF: La présente étude visait à comparer deux dispositifs différents pour la stimulation nerveuse, soit un stimulateur nerveux entièrement jetable et un stimulateur nerveux qu'utilisent les anesthésistes pour les blocages nerveux. MÉTHODOLOGIE: Les chercheurs ont effectué une étude rétrospective auprès de 60 patients qui avaient subi une opération du plexus brachial. Chez 30 patients, ils ont utilisé le stimulateur nerveux entièrement jetable (groupe I) et chez 30 autres, le dispositif d'anesthésie (groupe II). Les chercheurs ont calculé le coût des fournitures jetables utilisées pour la stimulation nerveuse dans chaque groupe. Le même chirurgien a effectué toutes les opérations et a été invité à donner son avis subjectif sur le caractère pratique et la facilité d'utilisation du dispositif dans chaque groupe. RÉSULTATS: Les dispositifs complètement jetables ont comme principaux avantages de se situer entièrement dans le champ stérile et d'être utilisés par le chirurgien sans qu'il communique avec l'anesthésiste. Cependant, ils comportent plusieurs désavantages par rapport au dispositif d'anesthésie. D'abord, ils peuvent seulement délivrer un stimulus de 0,5 mA, 1,0 mA et 2,0 mA, alors que les dispositifs d'anesthésie en délivrent de 0,1 mA à 5 mA (par incréments de 0,1 mA). Ensuite, le stimulateur jetable est souvent défaillant pendant la chirurgie, ce qui ne se produit pas avec le dispositif d'anesthésie. Enfin, le dispositif d'anesthésie réduit le coût des fournitures jetables. CONCLUSION: Le centre des chercheurs a cessé d'utiliser le stimulateur nerveux jetable au profit du dispositif d'anesthésie.

A newly identified novel variant in the CSF2RA gene in a child with pulmonary alveolar proteinosis: a case report.

BACKGROUND: The congenital form of pulmonary alveolar proteinosis due to colony stimulating factor 2 receptor alpha gene mutations is a rare disease with only a few cases reported worldwide. In this study we report a new case of pulmonary alveolar proteinosis with a novel variant in colony stimulating factor 2 receptor alpha gene. CASE PRESENTATION: A 5-year-old Saudi boy presented with a history of progressive dyspnea over 6 months; he was diagnosed as having pulmonary alveolar proteinosis. A molecular study revealed a novel variation in colony stimulating factor 2 receptor alpha gene. His clinical condition showed significant improvement after whole lung lavage. CONCLUSIONS: This case has the typical presentation of congenital pulmonary alveolar proteinosis due to colony stimulating factor 2 receptor alpha defect with a novel variant in this gene likely to be pathogenic.

Lung disease associated with filamin A gene mutation: a case report.

BACKGROUND: Mutations in the gene encoding filamin A (FLNA) lead to diseases with high phenotypic diversity including periventricular nodular heterotopia, skeletal dysplasia, otopalatodigital spectrum disorders, cardiovascular abnormalities, and coagulopathy. FLNA mutations were recently found to be associated with lung disease. In this study, we report a novel FLNA gene associated with significant lung disease and unique angiogenesis. CASE PRESENTATION: Here, we describe a 1-year-old Saudi female child with respiratory distress at birth. The child then had recurrent lower respiratory tract infections, bilateral lung emphysema with basal atelectasis, bronchospasm, pulmonary artery hypertension, and oxygen and mechanical ventilation dependency. Molecular testing showed a new pathogenic variant of one copy of c.3153dupC in exon 21 in the FLNA gene. CONCLUSIONS: Our data support previous reports in the literature that associate FLNA gene mutation and lung disease.

Clinical presentation of air leak in an infant with undiagnosed cystic fibrosis: a case report.

INTRODUCTION: Air leak is a well-recognized complication of advanced cystic fibrosis in older children and adults but is extremely rare in infants. To the best of our knowledge, this is the youngest reported pediatric case of an air leak from a major airway. CASE PRESENTATION: A 4-month-old Yamani baby girl with a family history of cystic fibrosis initially presented with a history of a persistent paroxysmal cough for 3 weeks and vomiting for 1 week. Laboratory evaluation indicated pseudo-Bartter's syndrome. Imaging showed a tracheal tear with pneumomediastinum and subcutaneous emphysema that was treated conservatively. CONCLUSIONS: This case highlights the possibility of air leak in the population of young patients with cystic fibrosis and it shows a successful conservative management of tracheal tear. Physicians should consider cystic fibrosis in infants presenting with air leak.

Endothelial dysfunction in children without hypertension: potential contributions of obesity and obstructive sleep apnea.

BACKGROUND: Endothelial dysfunction can develop in the context of both obesity and obstructive sleep apnea (OSA) in children. However, the potential interactions between OSA and obesity have not been defined. METHODS: Children who were prepubertal and nonhypertensive were recruited. Endothelial function was assessed in a morning fasted state, using a modified hyperemic test involving cuff-induced occlusion of the radial and ulnar arteries, and blood was drawn for assessment of myeloid-related protein 8/14 (MRP8/14) levels using a commercial enzyme-linked immunosorbent assay. Overnight polysomnography defined the presence of OSA or absence of OSA (NOSA) in subjects investigated for sleep-disordered breathing. Anthropometric measurements were performed to assign subjects to obese (OB) and nonobese (NOB) categories. RESULTS: Fifty-four children with OSA who were obese and nonobese (mean age, 7.90 ± 0.26 years; mean BMI z-score, 1.70 ± 0.3; obstructive apnea-hypopnea index [OAHI], 7.36 ± 1.09) were compared with 54 children without OSA who were obese and nonobese (mean age, 8.26 ± 0.24 years; mean BMI z-score, 1.41 ± 0.18; OAHI, 0.86 ± 0.07). Of those subjects, 62.5% of the OB-OSA category, 38.7% of the OB-NOSA category, and 20.0% of the NOB-OSA category had evidence of endothelial dysfunction, compared with 0.0% of the NOB-NOSA category (P < .01). The degree of endothelial dysfunction in all groups was associated with circulating MRP8/14 levels (r = 0.343, P < .001). CONCLUSIONS: Both obesity and OSA can independently increase the risk for endothelial dysfunction, and the concurrent presence of both markedly increases such risk. Although the mechanisms underlying endothelial dysfunction remain unclear, a potential role for MRP8/14 as an inflammatory biomarker of endothelial dysfunction is suggested.

Endothelial dysfunction in obese non-hypertensive children without evidence of sleep disordered breathing.

BACKGROUND: Endothelial dysfunction is a complication of both obesity and obstructive sleep apnea syndrome (OSAS), the latter being highly prevalent among obese children. It is unknown whether obesity causes endothelial dysfunction in children in the absence of OSAS. This study examines endothelial function in obese and non-obese children without OSAS. METHODS: Pre-pubertal non-hypertensive children were recruited. Endothelial function was assessed in a morning fasted state, using a modified hyperemic test involving cuff-induced occlusion of the radial and ulnar arteries. The absence of OSAS was confirmed by overnight polysomnography. Anthropometry was also performed. RESULTS: 55 obese children (mean age 8.6 +/- 1.4 years, mean BMI z-score: 2.3 +/- 0.3) were compared to 50 non-obese children (mean age 8.0 +/- 1.6 years, mean BMI z-score 0.3 +/- 0.9). Significant delays to peak capillary reperfusion after occlusion release occurred in obese compared to non-obese children (45.3 +/- 21.9 sec vs. 31.5 +/- 14.1 sec, p < 0.01), but no differences in the magnitude of hyperemia emerged. Time to peak reperfusion and percentage of body fat were positively correlated (r = 0.365, p < 0.01). CONCLUSIONS: Our findings confirm that endothelial dysfunction occurs early in life in obese children, even in the absence of OSAS. Thus, mechanisms underlying endothelial dysfunction in pediatric obesity are operational in the absence of sleep-disordered breathing.

Critical incident monitoring in a teaching hospital--the third report 2003-2008.

UNLABELLED: Several factors have been incriminated in the etiologies of critical incidents: shortages in organizing rules, anesthesia technique, patient environment, human factor, team work and communication. This is the third follow up report describing our performance during the last five years (2003-2008). The possible incriminating causes were identified with the objective of avoiding such eventualities and consequently providing a better patient outcome. PATIENTS & METHODS: The computerized database and the medical records of critical incidents reports in our Department during the period of 2003-2008 were reviewed on case-by-case basis. Seventy reported incidents were discussed in the Department's Morbidity & Mortality Meetings (MMM). Incidents were classified as per possible incriminating causes: pulmonary, cardiovascular, central nervous system, metabolic, inadvertent drug injection, communicating failure, equipment failure and miscellaneous causes. RESULTS: Most of the critical incidents reports occurred during maintenance of anesthesia, followed next by during induction and next by same operative day later in the ward. The majority of cases were respiratory events (29 cases), followed by communication failure (12 cases), failure of equipment (9 cases) and inadvertent drug injection (4 cases). CONCLUSIONS: Respiratory events, human errors, team communication and equipment failures, continue to be the leading causes of critical incidents. Critical incidents are apt to occur so long as the human factor is involved. Vigilance in operational efficiency and the scrutiny in drug administration, supervision and training should be closely monitored in order to minimize critical incident reports.