32 results for “procedural sedation”
5y · Male·Combined effects of prescribed morphine, valproic acid and midazolam leading to …
…psy, benzodiazepines, and other medications) underwent routine burn dressing change at hospital with oral sedation comprising morphine, midazolam, and paracetamol. The medications were administered concurrently rather th…
2y · Male·Cardiorespiratory arrest in a young child with opioid (morphine) toxicity
David Flynn was a healthy 2-year-8-month-old boy who died after circumcision under sedation with morphine at a private general practice clinic on 7 December 2021. Critical failures included: no fas…
39y · Female·aspiration pneumonia in the setting of general anaesthesia and colonoscopy for i…
…palsy, dysphagia, and sleep apnoea died from aspiration pneumonia following a colonoscopy performed under sedation for investigation of rectal bleeding. She had known increased aspiration risk, which was discussed with h…
63y · Female·Complications following sedation for percutaneous endoscopic gastrostomy (PEG) t…
…-year-old woman with profound disability from cerebral palsy and encephalitis, died from complications of sedation for PEG tube insertion. She had a congenital polymicrogyria, a significant neurological risk factor for a…
37y · Male·Respiratory arrest in association with medication drug effect and alcohol intoxi…
…misconceived handover suggesting he remained dangerously aggressive. The coroner found the sustained deep sedation was inappropriate; optimal sedation for such patients should maintain rousability. When the patient remov…
55y · Male·positional asphyxia, with sedation as an underlying risk factor
…disturbance related to medication changes and possible substance use. He received substantial intravenous sedation (75mg midazolam and 35mg haloperidol) over 20 hours at Royal North Shore Hospital ED, which was clinicall…
29y · Female·Hypoxic Encephalopathy consequent upon Cardiorespiratory Arrest arising from eit…
…aphylaxis post-procedure (likely cephalosporin-triggered) with cardiorespiratory arrest. The attending GP sedationist administered adrenaline but failed to intubate effectively, leaving her severely hypoxic for 15-20 min…
24y · Male·cardio-respiratory arrest due to multi-drug toxicity
…mbined with illicitly obtained buprenorphine. Clinical lessons include: monitoring for signs of excessive sedation despite therapeutic dosing; ensuring robust communication systems for clinically significant observations…
32y · Male·1(a) Aspiration of gastric contents; 1(b) Combined drug toxicity
…ocumented or performed), insufficient physiological monitoring (no vital signs on 21 August despite daily sedation, only two ECGs despite polypharmacy risk), and lack of pharmacist review of his medication regimen despit…
87y · Female·Pulmonary artery rupture complicating pulmonary artery catheter insertion in a w…
Mrs Jones, an 87-year-old woman with severe ischaemic heart disease, died from pulmonary artery rupture during elective off-pump coronary artery bypass surgery. A Swan-Ganz pulmonary artery catheter (PAC) was inserted pr…
59y · Female·acute cardiogenic shock, with acute mechanical obstruction of a remote mechanica…
…th a conscious patient, and lack of planning for uncommon procedures. Key learning: obtain consent before sedation, discuss novel/high-risk procedures thoroughly with patients, implement safety checklists matching proced…
27y · Male·Cardiac arrest due to cardiac arrhythmia triggered by prone restraint (some of w…
…alated to a prolonged prone restraint in a neighbour's house lasting 40+ minutes. Paramedics administered sedation without adequate monitoring or communication about positioning risks. Michael collapsed and died. Contrib…
40y · Male·respiratory failure due to Adult Respiratory Distress Syndrome (ARDS)
…ly one hour later he suffered cardiorespiratory arrest and subsequently died from ARDS. The coroner found sedation from multiple CNS depressants combined with his comorbidities (chronic obstructive airways disease, morbi…
38y · Male·End-stage respiratory failure secondary to kyphoscoliosis
Robert Edward Curry, a 38-year-old man with profound intellectual disability, cerebral palsy, severe kyphoscoliosis, and chronic respiratory compromise died from end-stage respiratory failure. A medication administration…
36y · Male·Undetermined; three possible mechanisms identified: oversedation with vomiting a…
…ntipsychotics. The coroner found the cause of death was undetermined, with three possible mechanisms: oversedation with aspiration, cardiac arrhythmia, or seizure. A significant systemic deficiency was identified: nursin…
55y · Male·Cardio-respiratory arrest due to mixed prescription drug sedation (clozapine and…
…hizophrenia, COPD, and cardiomyopathy, died from cardio-respiratory arrest due to mixed prescription drug sedation (clozapine and olanzapine) in the presence of advanced emphysema and acute bronchopneumonia. He was admit…
23y · Male·Acute cardiac arrhythmia in 3,4-methylenedioxymethylamphetamine (MDMA) intoxicat…
…he poorly ventilated police vehicle, the prone restraint in hospital lasted only about four minutes while sedation was administered. The coroner found no evidence of excessive restraint or procedural errors by hospital s…
38y · Male·abdominal and chest sepsis complicating iatrogenic left pneumothorax and laparot…
A 38-year-old man with chromosome 1 short arm deletion syndrome, intellectual disability, and scoliosis died from sepsis following iatrogenic pneumothorax and emergency laparotomy for small bowel obstruction. He was admi…
60y · Male·Multiple injuries sustained after jumping from 15th storey home unit
William MacKenzie, a 60-year-old with a five-year history of bipolar affective disorder and recent involuntary hospitalization, presented to St. Vincent's Hospital on 9 June 2008 with suicidal ideation after being found …
Male·Myocardial failure resulting from excessive pulmonary blood flow and consequenti…
…ation; a two-hour delay in intubating once clinical deterioration became obvious; and use of propofol for sedation during intubation, which may have contributed to myocardial depression. Despite these management issues, …
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