15 results for “arterial blood gas monitoring”
69y · Female·Asthma
…re to recognize development of chronic hypercapnic respiratory failure, over-reliance on oximetry without arterial blood gas monitoring, poor clinical documentation, and failure to escalate to senior staff overnight. The…
63y · Male·Right cerebral infarction caused by infusion of medication via central venous li…
…ein. Although this was recognised 36 hours later, medications including dextrose had been infused via the arterial line, causing right cerebral infarction. The clinician relied on absence of pulsatile flow and blood colo…
54y · Female·complications related to post-polio syndrome and chronic respiratory weakness; n…
Gabriele Hannemann, a 54-year-old woman with severe post-polio quadriplegia and chronic respiratory failure, died suddenly at home during consensual sexual activity. She had severely compromised lung function (13% predic…
25y · Male·Multiple system failure and ingestion of sodium nitrite
…3pm. He deteriorated to cardiac arrest at 10:26pm. The critical delay in treatment occurred because venous blood gas results showing severely elevated methaemoglobin (70-86%) were not configured to display reference ran…
78y · Male·cardiorespiratory failure due to complications of tracheal stenosis
…ently recorded, missing opportunities for escalation; (3) The critical airway narrowing warranted closer monitoring and potentially transfer to higher-level care; (4) An arterial blood gas test should have been performed…
0y · Female·subgaleal haematoma complicating an obstructed labour
…SGH was not identified until 7.30am, approximately 6 hours after birth. Earlier recognition and aggressive blood pressure support may have prevented deterioration, though outcome was likely poor. Key lessons: always com…
0y · Female·Persistent pulmonary hypertension in the newborn (PPHN)
…al. The coroner found Baby Summer died from PPHN but was not satisfied it was caused by sepsis despite low blood sugars and fluctuating oxygen requirements. While Dr M.'s management was generally appropriate, the corone…
69y · Female·Urosepsis secondary to anuric acute renal failure and corona radiata infarct; co…
…ith severe right-sided abdominal pain and vomiting. CT imaging at 10:00am confirmed emphysematous pyelitis (gas-forming kidney infection). Despite clear warning signs of developing sepsis over 19 hours—including progres…
35y · Male·Active rheumatic pancarditis complicated by pulmonary arterial hypertension, pne…
A 35-year-old Aboriginal man died from rheumatic pancarditis complicated by pulmonary hypertension, pneumonia and unspecified connective tissue disease. He had presented repeatedly to Katherine Hospital with symptoms sug…
21y · Female·Multiple organ failure due to undefined sepsis (toxic shock syndrome)
…shock with multi-organ failure in March 2012 after presenting with symptoms initially consistent with viral gastroenteritis and dehydration. Initial management at remote Paraburdoo Hospital was appropriate, but critical…
71y · Male·cardiac arrest due to hyperkalemia due to acute on chronic renal failure, with r…
…anaged preoperatively, and surgery should have been delayed pending renal consultation. Post-operatively, arterial blood gas measurements were not performed to assess acid-base status, and fluid management may have been …
Unknown·Ms Fensom: influenza A (H1N1 2009, pandemic swine flu) with myocarditis causing …
…g on 18 August, but the treating registrar (Dr V.) failed to recognise the seriousness of persistently low blood pressure despite it not responding to fluid therapy. Mr Taankink (26), an asthmatic, was prescribed Tamifl…
42y · Female·hypovolaemic shock due to an acute ruptured subcapsular splenic haematoma in the…
Eve Brown, a 42-year-old Aboriginal woman, died of hypovolaemic shock from a ruptured splenic haematoma in the context of urosepsis at a regional hospital. She presented with UTI symptoms and was admitted to Lightning Ri…
13y · Female·cerebral oedema and infarction secondary to extensive subdural empyema
Elly McCarthy, a 13-year-old girl, died from cerebral oedema and infarction secondary to subdural empyema. She developed fever, headache and neurological symptoms on 24 January 2004 and was initially seen at a GP and Noa…
47y · Male·Aspiration pneumonia due to or as a consequence of coronary atherosclerosis
…ated escalating supplementation, the desaturation event was not reported to medical staff, and overnight monitoring showed overwriting of low oxygen readings with falsely high ones after mask replacement. A junior enroll…
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