Abstract
Purpose
The low incidence of mortality and major morbidity in anesthesia makes it difficult to study the pattern of potential accidents and to develop preventive strategies. Anesthetic ‘near-misses’, however, occur more frequently. Using data from a simple routine-based system of problem reporting, we have analyzed the pattern and causes of serious non-fatal problems, in order to improve preventive strategies.
Methods
We prospectively recorded anesthesia-related information from all anesthetics for five years. The data included intraoperative problems, which were graded into four levels, according to severity. We analyzed only the serious nonfatal problems, which were sorted according to clinical presentation, and also according to which factor was most important in the development of the problem. We assessed any untoward consequences for the patient, and whether the problems could have been prevented.
Results
Serious problems were recorded in 315 cases out of 83,844 (0.4%). Anesthesia was considered the major contributing factor in III cases. Difficult intubation, difficult emergence from general anesthesia, allergic reactions, arrhythmia and hypotension were the dominating problems. Twenty-six anesthesia related problems resulted in changes in level of postoperative care, and one patient later died in the intensive care unit after anaphylactic shock. Eighty-two problems could have been prevented by simple strategies.
Conclusion
Analysis of serious nonfatal problems during anesthesia may contribute to improved preventive strategies. Data from a routine-based system are suitable for this type of analysis. Intubation, emergence, arrhythmia, hypotension and anaphylaxis cause most serious problems, and should be the object of preventive strategies.
Résumé
Objectif
La faible incidence de mortalité et de morbidité importante en anesthésie complique l’étude des types d’accidents potentiels et la mise au point de stratégies préventives. Les quasi accidents anesthésiques, par contre, surviennent plus fréquemment. En utilisant les données d’un simple système de notification de cours normal, nous avons analysé le type et les causes de problèmes graves, non mortels, dans le but d’améliorer les stratégies préventives.
Méthode
Nous avons enregistré prospectivement les informations reliées à toutes les anesthésies réalisées pendant cinq ans. Les données comprenaient les problèmes peropératoires que nous avons classés selon quatre niveaux de sévérité. Nous avons analysé les problèmes graves, non mortels, qui ont été retenus d’après la présentation clinique et aussi en fonction du facteur le plus important de l’évolution du problème. Nous avons évalué toutes les conséquences négatives pour le patient et la possibilité de prévention de ces problèmes.
Résultats
Des problèmes graves ont été notés dans 315 cas sur 83 844 (0,4 %). Lanesthésie a été considérée comme le principal facteur dans III cas. L’intubation difficile, le retour à la conscience difficile après l’anesthésie générale, les réactions allergiques, l’arythmie et l’hypotension ont dominé le tableau. Vingt-six problèmes reliés à l’anesthésie ont entraîné la modification des soins postopératoires et un patient est décédé à l’unité des soins intensifs d’un choc anaphylactique. Quatre-vingt-deux problèmes auraient pu être évités par de simples interventions.
Conclusion
Lanalyse de problèmes graves, mais non mortels, survenus pendant l’anesthésie peut contribuer à l’amélioration de stratégies préventives. Les données obtenus d’un système régulier de notification sont pertinentes à ce genre d’analyse. L’intubation, le retour à la conscience, l’arythmie, l’hypotension et l’anaphylaxie causent les problèmes les plus graves et devraient être prévenus.
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The study is supported with grants from the Norwegian Medical Research Council.
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Fasting, S., Gisvold, S.E. Serious intraoperative problems — a five-year review of 83,844 anesthetics. Can J Anesth 49, 545–553 (2002). https://doi.org/10.1007/BF03017379
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DOI: https://doi.org/10.1007/BF03017379