Review of unusual patient care experiences is a cornerstone of medical education. Each month, the AQI-AIRS Steering Committee abstracts a patient history submitted to the Anesthesia Incident Reporting System (AIRS) and authors a discussion of the safety and human factors challenges involved. Real-life case histories often include multiple clinical decisions, only some of which can be discussed in the space available. Absence of commentary should not be construed as agreement with the clinical decisions described. Feedback regarding this article can be sent by email to airs@asahq.org. Report incidents or download the AIRS mobile app at www.aqiairs.org.

A three-year-old male with a background of 32-week prematurity presented for scheduled circumcision. A resolving URI had started three weeks ago and had been treated with antibiotics. He received preoperative midazolam for anxiety and nebulized albuterol. He was calm on arrival...

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