Morbidity in anaesthesia: Today and tomorrow (original) (raw)

Mortality associated with anaesthesia: a qualitative analysis to identify risk factors

Anaesthesia, 2008

From a prospectively defined cohort of patients who underwent either general, regional or combined anaesthesia from 1 January 1995 to 1 January 1997 (n 869 483), all consecutive patients (n 811) who died within 24 h or remained unintentionally comatose 24 h after anaesthesia were classified to determine a relationship with anaesthesia. These deaths (n 119; 15%) were further analysed to identify contributing aspects of the anaesthetic management, other factors and the appropriateness of care. The incidence of 24-h peri-operative death per 10 000 anaesthetics was 8.8 (95% CI 8.2±9.5), of peri-operative coma was 0.5 (0.3±0.6) and of anaesthesia-related death 1.4 (1.1±1.6). Of the 119 anaesthesia-related deaths, 62 (52%) were associated with cardiovascular management, 57 (48%) with other anaesthetic management, 12 (10%) with ventilatory management and 12 (10%) with patient monitoring. Inadequate preparation of the patient contributed to 30 (25%) of the anaesthesia-related deaths. During induction of anaesthesia, choice of anaesthetic technique (n 18 (15%)) and performance of the anaesthesiologist (n 8 (7%)) were most commonly associated with death. During maintenance, the most common factors were cardiovascular management (n 43 (36%)), ventilatory management (n 12 (10%)) and patient monitoring (n 12 (10%)). In both the recovery and the postoperative phases, patient monitoring was the most common factor (n 12 (10%) for both). For cardiovascular, ventilatory and other anaesthetic management, human failure contributed to 89 (75%) deaths and organisational factors to 12 (10%). For inadequate patient monitoring, human factors contributed to 71 (60%) deaths and organisational factors to 48 (40%). Other contributing factors were inadequate communication (30 deaths (25%) for all four aspects of the anaesthetic management) and lack of supervision (particularly for ventilatory management). Inadequate care was delivered in 19 (16%) of the anaesthesia-related deaths with respect to cardiovascular management, in 20 (17%) with respect to ventilatory management, in 18 (15%) with respect to patient monitoring and in 23 (19%) with respect to other anaesthetic management.

Intraoperative Anesthesia-Related Mortality: A 10-Year Survey in a Tertiary Teaching Hospital

2021

Purpose: This study aimed to determine anesthesiarelated mortality and intraoperative mortality (IOM) incidences and the associated risk factors. Material and Methods: The operations between the years of 2010-2019 were retrospectively reviewed. It was found that 87 of 351,930 patients who were anesthetized in the last 10 years died. Each patient who died was recruited into one of the patient/condition-related, surgical-related, or anesthesia-related mortality groups. Patient characteristics were determined as age, gender, ASA PS score, and comorbidities. Surgical procedures were classified as minor/intermediate, major, and major complex. Anesthesia type was recorded. Operative time, the requirement for vasopressor and the invasive monitoring were determined. Results: The incidence of IOM and anesthesia-related mortality were 2.47 and 0.28 per 10,000 patients, respectively. The IOM group had a higher rate of out-ofhours work, surgical emergency, prolonged operative time, high comorbidity rate, high ASA PS score, major complex surgeries, use of VP, and invasive monitoring. Surgical emergency (p: 0.000), use of VP (p: 0.002), and invasive monitoring (p: 0.000) were independent determinants of IOM. Major complex surgeries (p: 0.007), surgical emergency (p: 0.000), use of VP (p: 0.002), and invasive monitoring (0.000) were potentially associated factors in anesthesia-related mortality. Conclusion: The incidence of IOM and anesthesia-related mortality were 2.47 and 0.28 per 10,000 patients, respectively. The fact that anesthesia-related mortality was associated with drug administration is important for the development of preventive measures. Primary prevention may play a key role in reducing the high fatality. These results indicate the need for improving medical perioperative practices in high-risk and emergency patients.

A survey of 112,000 anaesthetics at one teaching hospital (1975–83)

Canadian Journal of Anaesthesia-journal Canadien D Anesthesie, 1986

This paper describes the outcome of a nine-year post-anaesthetic followup program in a large teaching hospital (N = 112,721 anaesthetics). Between time periods 1975-78 and 1979-83, more seriously ill patients (higher ASA physical status) were being treated. Anaesthetic practice also changed, with an increased use of balanced (multiple drug) anaesthetic procedures, a decrease in the use of halothane and an increase in the use of monitoring. Nonfatal anaesthetic complications — intraoperative, recovery room and postoperative — were rare but there was an increase in the reported complication rate over time. From 1975-78, 7.6per cent of all cases had at least one intraoperative complication and from 1979-83, this rose to 10.6 per cent of all cases. For recovery room complications, there was an increase to5.9 per cent in 1979-83 from 3.1 per cent in 1975-78. In time period 2 there was a 9.4 per cent chance of having a postoperative anaesthetic-related complication, and a 0.45 per cent chance of a significant morbidity as a result. This represents an increase over time period 1 (8.9 and 0.40 per cent respectively). It is concluded that the anaesthetic experience, while associated with low mortality rates in recent years, is still associated with significant morbidity. It is conjectural at present whether this is refiective of preoperative patient status, anaesthetic practice, or other undefined variables associated with an operative experience. Ce papier expose les résultats de neuf ans d’étude d’un programme de suivie post-anesthésique dans un grand hôpital universitaire (N = 112,721 anesthésies). Pour les périodes de 1975-78 et 1979-83 plus de patients sérieusement malades (classe ASA plus élevés) ont été traités. La pratique anesthésique a aussi changé avec un accroissement dans l’utilisation d’une anesthésie balançée (l’utilisation de plusieurs drogues) la diminution dans l’utilisation de l’halothane et une augmentation dans l’utilisation des moniteurs physiologiques. Les complications anesthésiques non léthales pour les périodes per-opératoire, en salle de réveil et en période post-opératoire étaient rares. Cependant on a observé un accroissement dans le taux de complications rapporté à travers le temps. Pour la période de 1975-78, une complication per-opératoire a été rapportée pour 7,6 pour cent des cas. De 1979-83, ce pourcentage augmenta à 10.6 pour cent. Pour les complications survenant à la salle de réveil on observa un accroissement de 5.9 pour cent en 1979-83 à partir de 3.1 pour cent en 1975-78. Dans la deuxième période étudiée le risque d’avoir des complications post-opératoire reliées à l’anesthésie était de 9.4 pour cent avec 0.45 pour cent de risque d’avoir une morbidité significative. Ceci représente un accroissement par rapport à la première période de 8.9 et 0.40 pour cent respectivement. On conclut que l’expérience anesthésique même si elle est associée avec un taux de mortalité bas dans les dernières années reste pour le moins encore associée avec une morbidité significative. Il est hypothétique actuellement de penser que ceci peut être le reflet de l’état pré-opératoire du patient, de la pratique anesthésique ou tout autre variable indéfinie associée avec une expérience chiruricale.

Mortality in Anesthesia: A Systematic Review

Clinics, 2009

This systematic review of the Brazilian and worldwide literature aims to evaluate the incidence and causes of perioperative and anesthesia-related mortality. Studies were identified by searching the Medline and Scielo databases, followed by a manual search for relevant articles. Our review includes studies published between 1954 and 2007. Each publication was reviewed to identify author(s), study period, data source, perioperative mortality rates, and anesthesia-related mortality rates. Thirty-three trials were assessed. Brazilian and worldwide studies demonstrated a similar decline in anesthesia-related mortality rates, which amounted to fewer than 1 death per 10,000 anesthetics in the past two decades. Perioperative mortality rates also decreased during this period, with fewer than 20 deaths per 10,000 anesthetics in developed countries. Brazilian studies showed higher perioperative mortality rates, from 19 to 51 deaths per 10,000 anesthetics. The majority of perioperative deaths occurred in neonates, children under one year, elderly patients, males, patients of ASA III physical status or poorer, emergency surgeries, during general anesthesia, and cardiac surgery followed by thoracic, vascular, gastroenterologic, pediatric and orthopedic surgeries. The main causes of anesthesia-related mortality were problems with airway management and cardiocirculatory events related to anesthesia and drug administration. Our systematic review of the literature shows that perioperative mortality rates are higher in Brazil than in developed countries, while anesthesiarelated mortality rates are similar in Brazil and in developed countries. Most cases of anesthesia-related mortality are associated with cardiocirculatory and airway events. These data may be useful in developing strategies to prevent anesthesia-related deaths.

Anesthesia Management and Perioperative Mortality

Anesthesiology, 2006

To the Editor:-Mark Twain may have overstated his distrust of statistics, but the issue of interpretation of statistics comes to the forefront in the study by Arbous et al. 1 and the accompanying editorial by Warner. 2 As the results of the study are discussed, Arbous et al. jump from describing associations between outcomes and management factors, to cause-and-effect descriptions: "it was found. .. a checklist decreased the risk," "the reversal of the effect of opiates and muscle relaxants seems to decrease the risk," and so on. Warner embraces these ersatz "risks" as showing "anesthetic management processes to dramatically reduce perioperative mortality." When one looks at baseline characteristics of the study and control groups, there are, as the authors note, huge differences in the categories of urgent/emergent nature, time of day procedure performed, and American Society of Anesthesiologists physical status. In fact, 40% of the study cases were rated American Society of Anesthesiologists V-not expected to survive for 24 h, with or without surgery (regardless of anesthetic management). If we accept that a large proportion of the study cases carry greater risk by virtue of their physical status and the emergent nature of the injury or disease process, and that urgent/ emergent cases generally account for all the outside working hour cases, differences in anesthetic management processes between the two groups seem more coincidentally associated than causative. Were equipment checks performed less frequently in the study group because of the emergent nature of the cases? Was the lower percentage of two providers at termination of a procedure simply a function of the outside hour the procedure was performed? Was the lower reversal rate of opiates and muscle relaxants due to the fact that the study group was sicker, undergoing more complex procedures, and so remained intubated postoperatively? Did the study groups receive fewer narcotics and local anesthetics for postoperative pain because of their moribund (comatose?) or unstable condition? This is not to suggest that anesthesia practice factors do not affect morbidity and mortality; some of the anesthetic practice factors in this study may one day be proven to be causative. But let us appreciate the method of this study for what it is: a tool to identify associations. Those associations then need to be further studied to identify them as causative or coincidental. Cars manufactured on Monday do not have more problems than others because that day of the week starts with the letter M. We need to look for truths, damn truths, and more than associations.

Improving patient safety in medicine: is the model of anaesthesia care enough?

Swiss Medical Weekly, 2013

Avoiding iatrogenic adverse outcomes and providing safe care to patients is a priority in modern healthcare systems. Because anaesthetic practice is inherently risky, the specialty has developed a broad range of strategies to minimise human error and risk for patients. These are part of a hierarchical model developed by industrial safety experts to minimise risk. It is known as the safety hierarchy model. This review will describe the use of this model in anaesthesia and show why the specialty is often cited as a role model for patient safety improvement. It will also explore the extension of the model to other specialties and analyse its intrinsic limitations due to new challenges to patient safety: teamwork and communication issues. These will conclude the review.

Adverse events in anaesthesia care

Kontakt

The goal of this review study was to summarize research conclusions on reported adverse events in anaesthesia care regarding paediatric and adult patients in the last 10 years. Methods: Relevant sources were found in scientific databases EBSCO, PubMed, Science Direct, Wiley and Scopus. We used the following keywords: adverse events/incident/malpractice, anaesthesia, report. Other criteria for the inclusion of studies were: full-text, English language, publications that were no older than 10 years (2009-2019) and human related. In the end, we included 15 studies. Results: The studies (analytical, prospective, retrospective, cohort, observational, systematic revisions and meta-analyses) mostly specify the areas and frequencies of reported adverse events and deal with the efficiency of report procedures and their implementation in clinical practice. The most frequent adverse events that occurred in anaesthesia care were respiration and cardiovascular problems and medical errors. The level of their occurrence varied by the patients' age. Conclusions: The monitoring and assessment of adverse events is an effective instrument for the improvement of quality and safety in anaesthesia practical care. The main problem is the unwillingness of medical workers to participate in reporting adverse events and the incompatibility of adverse event databases in anaesthesia care.