AB COVER CD algorithm
| Description | Number | ||||
|---|---|---|---|---|---|
| E/S* | BrPl† | Oph‡ | |||
| Total sample included *E/S, epidural or spinal block cases (98 epidural, 91 spinal, 4 combined, 3 caudal); †BrPl, brachial plexus block cases (12 axillary block, 5 interscalene block, 3 supraclavicular block, 1 not stated); ‡Oph, ophthalmic block cases (9 peribulbar, 9 retrobulbar, 5 not stated). | |||||
| A | Airway | – | – | – | |
| B | Breathing (3 cases) | ||||
| Apnoea during LSCS (1), delayed respiratory depression (1) | 2 | – | – | ||
| Laryngeal nerve palsy | – | 1 | – | ||
| C | Circulation (pulse) | – | – | – | |
| Although some of the cases of hypotension and dysrhythmia may have been detected by feeling the pulse volume, these are included at the C stage of CD in the algorithm as they would be detected during the systematic check of the circulation (see Circulation, below) | |||||
| Colour (4 cases) | |||||
| Hypoxia during sedation | 2 | – | 1 | ||
| Hypoxia during positioning | 1 | – | – | ||
| O | Oxygen supply to patient | – | – | – | |
| Oxygen analyser | – | – | – | ||
| V | Ventilation | – | – | – | |
| Vaporisors (4 cases) | |||||
| Vaporiser left on | 2 | 1 | – | ||
| Overfilled vaporiser | 1 | – | – | ||
| E | Endotracheal tube | – | – | – | |
| Eliminate | – | – | – | ||
| R | Review monitors (8 cases) | ||||
| Blood pressure measurement: inappropriate cuff application (1); not turned on (1); failure to measure (1); erroneous reading (1) | 4 | – | – | ||
| Capnograph: CO2 water trap missing | 1 | – | – | ||
| Electrocardiogram: incorrect rate | 1 | – | – | ||
| No foetal heart monitor | 1 | – | – | ||
| Hypothermia | 1 | – | – | ||
| Review equipment (8 cases) | 1 | – | – | ||
| Intravascular air | 1 | – | – | ||
| Surgeon punctured intravenous line | 1 | – | – | ||
| Leaking Haemaccel flask | 1 | – | – | ||
| No IV access – forgotten | 1 | – | – | ||
| Burn via diathermy | 1 | – | – | ||
| Drug fridge turned off | 1 | – | – | ||
| Wrong table | 1 | – | – | ||
| Fell off table | – | – | 1 | ||
| C | Circulation (60 cases) | ||||
| Hypotension (25 spinal cases including 4 deaths, 10 epidural cases including 2 deaths, 1 brachial plexus case) | 35 | 1 | – | ||
| Bradycardia (7 spinal, 5 ophthalmic cases) | 7 | – | 5 | ||
| Hypertension (3 spinal) | 3 | – | – | ||
| Myocardial infarction (2 spinal, 1 epidural) | 3 | – | – | ||
| Ventricular tachycardia (1 spinal) | 1 | – | – | ||
| Supraventricular tachycardia (1 spinal, 1 ophthalmic) | 1 | – | 1 | ||
| Arrhythmia (1 brachial plexus) | – | 1 | – | ||
| Left ventricular failure (2 ophthalmic) | – | – | 2 | ||
| D | Drugs (22 cases) | ||||
| Wrong drug | Syringe swap | 5 | – | – | |
| Wrong local anaesthetic | 2 | – | – | ||
| Wrong concentration | 6 | – | – | ||
| Drug not given | 2 | – | – | ||
| Communication problem | Communication about subcutaneous heparin | 1 | – | – | |
| Communication about intrathecal morphine | 1 | – | – | ||
| Wrong route | Inadvertent epidural metaraminol | 2 | – | – | |
| Inadvertent epidural ranitidine | 1 | – | – | ||
| Epidural infusion connected to intravenous infusion | 2 | – | – | ||